BACKGROUND:Emergency physicians (EPs) often care for patients with acute small bowel obstruction. While some patients require exploratory laparotomy, others are managed successfully with supportive care. We aimed to determine features that predict the need for operative management in emergency department (ED) patients with small bowel obstruction (SBO). METHODS:We performed a retrospective chart review of 370 consecutive patients admitted to a large urban academic teaching hospital with a diagnosis of SBO over a two-year period. We evaluated demographic characters (prior SBO, prior abdominal surgery, active malignancy) and clinical findings (leukocytosis and lactic acid) to determine features associated with the need for urgent operative intervention. RESULTS:Patients with a prior SBO were less likely to undergo operative intervention [20.3％ (42/207)] compared to those without a prior SBO [35.2％ (57/162)]. Abnormal bloodwork was not associated with need for operative intervention. 68％ of patients with CT scan findings of both an SBO and a hernia, however, were operatively managed. CONCLUSIONS:Patients with a history of SBO were less likely to require operative intervention at any point during their hospitalization. Abnormal bloodwork was not associated with operative intervention. The CT finding of a hernia, however, predicted the need for operative intervention, while other findings (ascites, duodenal thickening) did not. Further research would be helpful to construct a prediction rule, which could help community EPs determine which patients may benefit from expedited transfer for operative management, and which patients could be safely managed conservatively as an initial treatment strategy.