Computed tomography (CT) has become an essential tool in the assessment of intestinal lesions worldwide, and its specific diagnostic accuracy and clinical outcomes in the unique epidemiological and health environment of Saudi Arabia have not been measured. The purpose of the study was to identify the diagnostic accuracy of CT in intestinal pathologies and assess typical imaging appearances as well as the effect of CT on clinical management in a Saudi tertiary care cohort. The study involved a retrospective diagnostic accuracy study of 427 patients with histopathologically proven intestinal lesions. Diagnostic measures were derived against the histological gold standard, and imaging characteristics were examined, and management changes after CT were monitored. CT showed a diagnostic accuracy of 82.9%(95%CI:78.9-86.4), a high degree of specificity (>94% of both neoplastic and ischemic lesions), and sensitivity of ischemia (79.3%). An accurate CT diagnosis was a strong predictor of a change of clinical management (p<0.001). There were also characteristic features that markedly distinguished the pathologies; neoplastic lesions had higher wall thickness (14.2+4.5 mm) and lacked mural stratification (9.7%), whereas inflammatory/ischemic conditions had stratification (87.0-89.7%). This study supports the use of CT as a very specific and clinically decisive method in this context, but in early ischemia, there is a diagnostic problem. The results can be seen as evidence-based confirmation of local practice and indicate the necessity to use sophisticated methods to increase sensitivity.