Adhesive small bowel obstruction (SBO) remains one of the leading causes of emergency room visits and is still associated with high morbidity and mortality rates. Because the management of adhesive SBO has shifted from immediate surgery to nonoperative treatment in the absence of ischemia, it is crucial to rapidly detect or predict strangulation, which requires emergent surgery. CT is now established as the best imaging technique for the initial assessment of patients suspected of having adhesive SBO. CT helps confirm the diagnosis of mechanical SBO, locate the site of obstruction, establish the cause, and detect complications. This article is a review of the role of imaging in answering specific questions to help predict the management needs of each individual patient. It includes (a) an update on the best CT signs for predicting ischemia and a need for bowel resection; (b) a discussion of the CT features that help differentiate open-loop from closed-loop obstruction and a single adhesive band from matted adhesions and how these differences can influence the management; and (c) a review of the main CT predictors of the success or failure of nonoperative management in adhesive SBO.