Bowel problems occur in 27% to 62% of patients with spinal cord injuries (SCI), most commonly constipation, distention, abdominal pain, rectal bleeding, hemorrhoids, bowel accidents, and autonomic hyperreflexia. The acute abdomen, with a mortality of 9.5%, does not present with rigidity or absent bowel sounds but rather with dull/poorlylocalized pain, vomiting, or restlessness, with tenderness, fever, and leukocytosis in up to 50% of patients. Fecal impaction may present with anorexia and nausea. Methods used for bowel care include laxatives, anal massage, manual evacuation, and enemas. Randomized, double-blind studies demonstrated the effectiveness of neostigmine, which increases cholinergic tone, combined with glycopyrrolate, an anticholinergic agent with minimal activity in the colon that reduces extracolonic side-effects. Improved bowel function occurs with anterior sacral root stimulators which may be combined with an S2 to S4 posterior sacral rhizotomy which interrupts the reflex arc by cutting the posterior roots carrying the spasticity-causing sensory nerves. For severe constipation, a colostomy reduces time for bowel care, providing a clean environment so decubitus ulcers may heal. Gallstones occur in 17% to 31% of patients, and acalculous cholecystitis in 3.7% of patients with acute SCI. A high index of suspicion is needed to properly diagnose bowel problems in SCI.