Background: Acute colonic pseudo‐obstruction is characterized by clinical and radiological evidence of acute large bowel obstruction in the absence of a mechanical cause. The condition usually affects elderly people with underlying co‐morbidities, and early recognition and appropriate management are essential to reduce the occurrence of life‐threatening complications. Methods: A part‐systematic review was conducted. This was based on key publications focusing on advances in management. Results and conclusions: Although acute colonic dilatation has been suggested to result from a functional imbalance in autonomic nerve supply, there is little direct evidence for this. Other aetiologies derived from the evolving field of neurogastroenterology remain underexplored. The rationale of treatment is to achieve prompt and effective colonic decompression. Initial management includes supportive interventions that may be followed by pharmacological therapy. Controlled clinical trials have shown that the acetylcholinesterase inhibitor neostigmine is an effective treatment with initial response rates of 60–90 per cent; other drugs for use in this area are in evolution. Colonoscopic decompression is successful in approximately 80 per cent of patients, with other minimally invasive strategies continuing to be developed. Surgery has thus become largely limited to those in whom complications occur. A contemporary management algorithm is provided on this basis. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. Management algorithm suggested