Radiographic evaluation of dilated small bowel disease is best approached by categorization of the mucosal fold pattern. This review illustrates a differential diagnosis of the most common pattern of dilated small bowel disease. The presence of dilated small bowel with thin and straightened valvulae conniventes is most commonly seen with obstruction, particularly when long segment or diffuse disease is identified. However, one must consider rare forms of obstruction, like SMA syndrome and post-surgical internal hernias, non-obstructive adynamic ileus, celiac disease and scleroderma. When the process is more focal or segmental, additional causes such as aneurismal lymphoma, gastrointestinal stromal tumors (GIST) and massive small bowel diverticula may also be considered.