A 21-year old Arabian gelding presented to Cornell University Equine and Nemo Farm Animal Hospital Emergency service with a history of acute colic signs starting about 4 hours previously. The referring veterinarian noted a high-normal heart rate (40 beats/min) and an enlarged but indentable large colon on rectal examination. Physical exam at presentation showed tachycardia, tachypnea, pale and tacky mucous membranes with a prolonged capillary refill time, severely decreased to absent gastrointestinal sounds in all quadrants, dark, rancid fluid from the nasogastric tube, and multiple loops of dilated small intestine ventral to the enlarged large colon. Initial diagnostics included bloodwork (packed cell volume, total solids, and iSTAT that measured electrolytes), abdominal ultrasound, and peritoneal fluid analysis. No significant abnormalities were noted on point-of-care bloodwork. Ultrasound revealed multiple abnormalities, most importantly many loops of dilated, thickened, and non-motile small intestine. Peritoneal fluid analysis indicated severe inflammation of the intestine. Together, these findings strongly suggested small intestinal strangulation. Surgical exploration was recommended and a large, pedunculated lipoma was found strangulating approximately 20 feet of small intestine. A jejuno-ileal anastomosis was performed and the horse recovered well with few complications, and is still well as of July 2017. This case report will describe the clinical case outlined above and a summary of strangulating lipoma treatments and common outcomes in horses.