Missed small bowel obstruction that complicated an acute appendicitis: a misdiagnosis

We present a case of an 11-year-old boy who had an abdominal pain for 4 days, which was found to be caused by an acute appendicitis that ruptured. The second day after an open appendectomy, he was found to have a small bowel obstruction that was not found during the procedure. The reasons for this misdiagnosis are discussed in this article to help other health care providers avoid this dangerous complication.