Summary: Sclerosing mesenteritis (SM) is an idiopathic condition characterized by chronic inflammation, fibrosis, and necrosis of mesenteric adipose tissue. Due to its rarity, standardized recommendations for the diagnosis, treatment, and monitoring of this condition have not yet been established. Computed tomography (CT) is the preferred imaging modality for diagnosis, typically evaluated using the Coulier five-point classification. Biopsy is not required if three or more of these criteria are present. However, increased mesenteric fat density on CT may also occur in other conditions, including mesenteric oedema or haemorrhage, inflammatory cell infiltration, and malignancy; therefore, an appropriate differential diagnosis is essential. If mesenteric malignancy is suspected, further diagnostic evaluation, including positron emission tomography (PET) and biopsy, is recommended to establish a definitive diagnosis. The clinical course is usually benign, and approximately 60% of patients remain asymptomatic. In some cases, however, the disease may lead to severe complications requiring urgent treatment, including surgical intervention. The most common symptom is abdominal pain. In such cases, treatment should initially include neuromodulators. In patients with severe symptoms or complications, first-line therapy consists of prednisone in combination with tamoxifen. In asymptomatic patients with characteristic CT findings of SM and no diagnostic uncertainty, follow-up CT imaging is recommended every two years, with additional imaging if alarming symptoms develop. The potential association between SM and neoplasia has been debated for many years. Current expert opinions do not support a causal relationship; however, imaging findings of SM appear to be associated with the diagnosis of certain malignancies, including gynecological cancers, carcinoid tumors, and lymphomas.