We compared patients with small bowel obstruction (SBO) admitted through the emergency department to the surgical service (SS) with those admitted to the medical service (MS) with respect to outcomes and healthcare cost. We conducted a retrospective analysis of our SBO database comparing 482 patients admitted to SS and 153 patients admitted to MS at a single institution over a 5-year period (January 2003 to December 2007). Study outcomes included length of hospital stay (LOS), time to surgery (TTS), hospital charges, incidence of bowel resection, and mortality. Both groups were comparable for age, gender, and race. The SS group had a shorter LOS (6.1 vs. 7.5 days; P = 0.01), less hospital charges ($29,549 vs. $35,789; P = 0.06), shorter TTS (log rank comparison; P = 0.006), and less mortality (eight [1.66%] vs. six [3.92]; P = 0.11). The SS group had more bowel resections (13.1 vs. 5.2%; P = 0.007). Coronary artery disease (CAD), acute renal failure (ARF), admission to SS, and female gender were significant predictors of bowel resection. CAD and ARF were significant predictors of mortality. Two hundred forty-four patients required operative intervention (surgery operative subgroup [SOS] 210 [43.6%], medicine operative subgroup [MOS] 34 [22.2%]). SOS and MOS were comparable for gender and race. SOS had shorter LOS (9.1 vs. 12.3 days; P = 0.02), less hospital charges ($46,258 vs. $62,778, P = 0.05), and less mortality (eight [3.81%] vs. four [11.76%]; P = 0.07). Bowel resection was comparable (SOS 30% vs. MOS 23%; P = 0.44). CAD and congestive heart failure (CHF) were significant predictors of bowel resection, whereas CAD was the only significant predictor of mortality in this subgroup. We recommend that patients with SBO be admitted to SS because this might translate to shorter LOS, earlier operative intervention, and reduced healthcare use direct cost. Bowel resection and death are more likely to occur in patients with comorbidities like CHF, CAD, diabetes mellitus, and ARF.