An 80 year old female patient was admitted as an emergency with abdominal pain, distension and constipation. Her past medical history included mild hypertension. On admission she was afebrile, with a BP of 146/79, and pulse of 110. On examination of the abdomen she had distension with lower abdominal tenderness. Abdominal XR showed dilated small and large bowel loops. The WCC (White Cell Count) was raised at 12.6, with CRP of 54 & bilirubin of 34. A CT scan of the abdomen showed large bowel obstruction thought to be secondary to a sigmoid carcinoma. A solid mass in the right adnexa was also noted and thought to be either a primary ovarian tumour or metastatic deposit. No distant disease was seen. After a period of resuscitation, a laparotomy was performed. The large bowel obstruction was found to be secondary to a "sigmoid tumour". The uterus and right ovary were abnormal and were "fixed" to the upper rectum distal to the tumour. The appendix was noted to be abnormal with palpable ileocaecal lymph nodes. A low Hartman's was performed with en-bloc total hysterectomy and bilateral salpigo-oophorectomy. A separate Ileocaecal resection with end ileostomy was also performed. Postoperatively the patient made an uneventful recovery and she was discharged home two weeks later. Macroscopic examination of the specimen showed an appendix measuring 40 mm in length and up to 15 mm in diameter. Microscopic examination showed invasive high grade adenocarcinoma of appendiceal origin showing diffuse infiltration of the wall of the appendix and the caecum with serosal extension. Metastatic tumour was seen in 2 out of 9 ileocaecal lymph nodes. Distant metastatic carcinoma was also shown to involve the wall of the distal sigmoid colon with stricture formation and infiltration of the adherent uterus, cervix, both ovaries and right fallopian tube. Immunohistochemistry showed that in all areas of tumour infiltration identical staining was identified. There was strong CK20 positivity, patchy chromogranin positivity and negative staining for CK7. There was similarity in appearance to a malignant goblet cell carcinoid although the tumour was classified as a high-grade aggressive adenocarcinoma of the appendix with neuroendocrine differentiation. The patient was started on Chemotherapy, but 2 weeks into her treatment she declined any further Chemotherapy as she felt very unwell with it Two years postoperatively the patient remains well with a clear surveillance CT scan. In our review of the literature, some other unusual presentations of appendiceal tumours have also been reported, they included an appendiceal adenocarcinoma presenting as a vesical fistula [], neck mass and vaginal bleeding [], spontaneous skin fistula [], caeco-colic intussusception [], disseminated ovarian carcinoma []. There was also a reported case of adenocarcinoma of the appendix masquerading as a bladder tumour [], a uterine tumour [], and a case presenting as an inguinal hernia [].