Acute mesenteric ischemia (AMI) is a rare cause of acute abdomen. Coupled with a high patient age, non-specific clinical symptoms and a significant co-morbidity the disease is still associated with a significant mortality of 60-85%. With a combination of preexisting cardiac arrhythmia and sudden abdominal pain AMI should always first be ruled out. Contrast-enhanced computed tomography (CT) scanning has replaced angiography as the first diagnostic step, largely because both intravascular and intra-abdominal pathologies can be diagnosed. In the case of an acute abdomen or lack of immediate access to diagnostic tools, rapid surgical exploration should be preferred. Surgical therapy includes embolectomy and resection of ischemic bowel segments. There should be a wide indication for second-look surgery. The most important prognostic factor and the only factor that can be influenced by the surgeon is the time interval between onset of symptoms and surgery. Therefore angiography or laparotomy should be performed as early as possible in cases of suspected AMI.