Per- and polyfluoroalkyl substances (PFAS) are persistent environmental contaminants widely detected in freshwater and marine ecosystems, where they accumulate in aquatic organisms and may pose ecological and human health risks. This review provides a mechanism-oriented synthesis of PFAS occurrence, internal accumulation processes, and trophic transfer in fish across diverse aquatic environments. Rather than relying solely on concentration-based summaries, this study integrates physicochemical properties, protein-binding behavior, organismal physiology, and environmental drivers to explain variability in reported PFAS burdens. Compiled data reveal substantial variability in PFAS concentrations among species, tissues, and geographic regions, reflecting both environmental heterogeneity and methodological differences in analytical approaches and reporting bases. Among individual compounds, perfluorooctane sulfonate (PFOS) consistently emerges as a dominant PFAS, likely due to its historical production, environmental persistence, and strong affinity for protein-rich tissues. The highest reported concentration was observed in fish liver from Lake Halmsjön, Sweden (3900 ± 500 ng/g wet weight). Tissue-specific accumulation patterns, particularly elevated concentrations in metabolically active organs, are primarily governed by protein-binding interactions rather than lipid partitioning. While higher PFAS levels in fish are generally associated with elevated aqueous concentrations, this relationship reflects environmentally mediated exposure rather than definitive trophic magnification. Moreover, inconsistent relationships between fish morphometrics and contaminant burdens can be explained by competing physiological processes, including cumulative exposure and growth dilution. From a human health perspective, fish consumption represents a relevant exposure pathway for certain PFAS; however, risk characterization remains sensitive to assumptions regarding dietary intake, tiss