Contemporary management of large bowel obstruction: What you need to know

Large bowel obstruction (LBO) accounts for approximately one-quarter of all intestinal obstructions. LBO may arise from mechanical obstruction due to benign or malignant etiologies, or from functional obstruction such as acute colonic pseudo-obstruction. Because clinical presentation varies by acuity, etiology, and ileocecal valve competency, early recognition and prompt evaluation are essential to prevent complications, including ischemia and perforation with potential for sepsis and mortality. Patients with acute obstruction typically present with abdominal pain, distension, and obstipation, whereas malignant obstruction often develops gradually with progressive constipation and abdominal distension, leading to dehydration, electrolyte abnormalities, and malnutrition. Computed tomography has become the preferred diagnostic modality due to its ability to identify the transition point, help define the cause and severity of obstruction, and potentially detect complications such as ischemia or perforation. Endoscopy serves both diagnostic and therapeutic roles in selected patients, including detorsion for sigmoid volvulus, decompression for pseudo-obstruction, and tissue diagnosis or stent placement in malignant obstruction. Initial management focuses on resuscitation, correction of electrolyte abnormalities, mitigation of aspiration risk, and gastrointestinal decompression. Definitive management depends on the underlying etiology. Malignant LBO requires individualized planning based on tumor location, patient physiology, and institutional expertise, with options including oncologic resection with or without colostomy, proximal surgical diversion and staged resection, or endoscopic stenting with staged resection. Self-expanding metallic stents may serve as bridges to surgery and reduce the need for a stoma. Benign causes, including diverticular strictures, volvulus, inflammatory bowel disease-related strictures, anastomotic strictures, and fecal impaction, require tailored endoscopic or operative interventions. Across etiologies, short delays to intervention may be appropriate for stable patients undergoing optimization; however, early definitive management should be the usual approach. In cases where intervention is delayed, careful surveillance for developing ischemia or perforation is mandatory. ( J Trauma Acute Care Surg . 2026;101: 1-12. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved).