An 81-year-old man presented with a 1-day history of right iliac fossa pain that radiated to the left iliac fossa. Vital signs were normal. Examination revealed abdominal distension with peritonism. An abdominal x-ray showed small bowel obstruction, and a computed tomography scan suggested a small bowel volvulus.

Laparotomy revealed a small bowel obstruction due to a pendulous appendix (20 cm in length) that had wrapped around a loop of bowel, causing obstruction and ischaemia (Figure).

Histopathological examination confirmed the presence of acute appendicitis with ischaemic small bowel. The patient recovered uneventfully.

The average length of the adult appendix is 7.5 cm in men and 6.7 cm in women (SD, 2.1 cm; range, 2–26 cm).1 Small bowel obstruction secondary to “appendiceal tourniquet” is extremely rare, with only 12 cases previously reported.2,3