Small intestinal necrosis is a life-threatening surgical emergency. We report a case of small intestinal necrosis in a previously healthy child. The diagnosis was made at the explorative operation; however, we could not find any evidence of acute appendicitis or mechanical obstruction on imaging studies and even at laparotomy. A 23-month-old boy was admitted with a history of non-bilious vomiting, abdominal pain, and fever for two days. His medical history and family history were unremarkable. His abdomen was soft with normoactive bowel sound. There was mild tenderness on whole abdomen. Laboratory tests revealed C reactive protein 6.35 mg/dL, sodium 130 mmol/L, chloride 90 mmol/L. Erect abdominal x-ray showed abnormal dilatation of small bowel loops with air-fluid levels, suggestive of a possible small bowel obstruction. An abdominal US revealed wall thickening of small bowel loops, several enlarged lymph nodes, no evidence of intussusception, and normal appendix. He was resuscitated and intravenous cefotaxime was administered. Next day, his condition rapidly deteriorated and seemed to go into septic shock. Tachycardia and tachypnea were developed. Repeated laboratory test revealed C reactive protein 28.96 mg/dL, sodium 129 mmol/L, albumin 2.6 g/dL, prothrombin time at 21.5 sec and activated partial thromboplastin time at 56 sec. Venous blood gas analysis demonstrated pH 7.28, bicarbonate 15 mmol/L. Urgent abdomen CT revealed diffuse dilatation of bowel loops suggestive paralytic ileus, mesenteric lymphadenitis and scanty ascites. Despite medical therapy, he became more lethargic. His abdomen was increasingly distended with hypoactive bowel sound. Muscle guarding or tenderness was not clear. Generalized edema and oliguria developed. He was taken for urgent exploratory laparotomy. A segment of strongly dilatated and infarcted small bowel was identified. Intussusception or volvulus was not present. Appendix appeared macroscopically unremarkable. Total 110 cm of distal small bowel was resected and end-to-end small bowel anastomosis was performed. The postoperative course was uneventful and he was discharged in good general condition. Even though there is no clue for a conclusive diagnosis which needs a surgical intervention on imaging studies, the timely explorative surgical approach should be chosen based on careful clinical suspicion and evaluations.