Silent Strangulation: Closed-Loop Small Bowel Obstruction with Preserved Enhancement and Minimal Clinical Symptoms

Closed-loop small bowel obstruction is a surgical emergency associated with a high risk of strangulation and bowel ischemia. Clinical presentation may be deceptively mild, and imaging findings can be subtle, leading to delayed diagnosis. We report a case of closed-loop mid-ileal obstruction with progressive free intraperitoneal fluid and preserved bowel wall enhancement on contrast-enhanced computed tomography. Despite minimal clinical symptoms and transient pain relief, surgical exploration revealed gangrenous bowel requiring resection. This case highlights the importance of recognizing free intraperitoneal fluid as a critical indirect imaging marker of bowel ischemia and emphasizes the need for early surgical intervention based on radiological suspicion rather than clinical severity alone.