OBJECTIVE : Superior mesenteric venous thrombosis (MVT) is a poorly understood clinical entity, and as such, outcomes are poorly described. This study aimed to identify predictors of bowel ischemia after MVT and to compare outcomes for patients treated medically (group 1) with those for patients treated with bowel resection (group 2). METHODS : This was a retrospective, single-institution study capturing all patients diagnosed with symptomatic acute MVT on computed tomography imaging from 2008 to 2018. Demographics, comorbidities, imaging, laboratory values, and treatment were included. Predictors of bowel resection were analyzed by univariate and multivariate statistics. Outcomes including mortality, readmissions for abdominal pain, and chronic mesenteric venous congestion were compared using χ2 test. RESULTS : There were 121 patients included in the study; 98 patients were treated medically (group 1), 19 patients were treated with bowel resection (group 2), and 4 patients were treated with endovascular recanalization (group 3). Group 1 and group 2 were compared directly. Patients requiring bowel resection tended to have higher body mass index (P = .051) and a hypercoagulable disorder (P = .003). Patients who required bowel resection were more likely to present with lactic acidosis (P < .001) and leukocytosis (P < .001) with bowel wall thickening on scan (P < .001). On multivariable analysis, a genetic thrombophilia was a strong predictor of bowel ischemia (odds ratio, 3.81; 95% confidence interval, 1.12-12.37). One-year mortality and readmission rates did not differ between groups. However, readmission rates for abdominal pain were high for both groups (group 1, 44.90%; group 2, 57.89%; P = .317), and a significant proportion of patients exhibited chronic mesenteric venous congestion on repeated scan (group 1, 42.86%; group 2, 47.37%; P = .104). CONCLUSIONS : A genetic hypercoagulable disorder is a predictor of bowel ischemia due to MVT. Regardless of treatment, outcomes after MVT are morbid, with high rates of readmission for abdominal pain. An alternative approach to treat these patients is needed, given the poor outcomes with current strategies.