This is a very tricky case with unexpected outcomes either clinically or radiologically. The patient is middle-aged, his pain was mainly epigastric and right-sided, no atherosclerosis, no cardiac disease, no relevant past history. Why anyone could expect mesenteric ischemia on such occasions. One important clinical sign was present and could be helpful: the pain is not relieved by analgesics.

In this case, we note how subtle and easily missed bowel changes in arterial ischemia, the bowel wall is not thickened even thinned out and the pneumatosis was very subtle. Also, note how very clear mesenteric fat. This is completely different from venous ischemia in which there is marked wall thickening, intramural hemorrhage, and blurred edematous mesenteric fat.

In routine single-phase portal venous CT study, the mission will be more and more difficult as the degree of arterial enhancement will not be conclusive.

In this case, the proximal jejunum remains viable due to patent proximal jejunal branches and the right colon also remains viable despite right colic artery occlusion due to supply by the marginal artery of Drummond.

Surprisingly the patient survived postoperatively, and was discharged in a good condition however he will need special care due to his new problem "short-gut syndrome" 

Mesenteric ischemia is a nightmare for radiologists. Here are some important points to remember:

• evaluation of the visceral arteries and veins should be a routine part of the assessment of CT abdominal study even the clinical scenario is so away from ischemia.
• follow the artery and vein along their courses with the assessment of their small branches
• consider multiphasic contrast-enhanced CT in cases of acute abdomen.
• gangrenous bowel secondary to arterial mesenteric ischemia has no thickened wall but even thin wall and pneumatosis may be minimal if any. This is so different from venous mesenteric ischemia

Intraoperative photos contribution by Dr/ Adel Abdelwahed