A review of case records and post-mortem reports from Glasgow Royal Infirmary over the past 12 years identified 102 patients with acute superior mesenteric ischaemia, 53 (52 per cent) of whom were first diagnosed at post mortem. Overall mortality was 92 per cent and mortality in the 49 patients diagnosed in life was 84 per cent. Fourteen patients (14 per cent) underwent exploratory laparotomy only with no survivors, 26 (25 per cent) had bowel resection alone with 7 surviving, and 9 (9 per cent) had a revascularization procedure, 5 requiring additional bowel resection, with only one surviving. Survivors were usually younger, had a shorter history and less extensive bowel infarction. Improvements in intensive care and nutritional support with the greater use of revascularization procedures in the past 6 years have barely influenced mortality. Delays in diagnosis and treatment contribute to the poor results. Earlier diagnosis might be aided by measuring serum inorganic phosphate and, coupled with the more widespread use of emergency angiography and revascularization procedures, holds out the best hope for future improvement.