Colonic pseudo-obstruction is often confused with mechanical intestinal obstruction. It occurs when there is an autonomic imbalance resulting in sympathetic over-activity affecting some part of the colon. The patient is often elderly with numerous comorbidities. Once mechanical obstruction is excluded by contrast enema, the patient should be treated conservatively with nasogastric and flatus tubes for at least 48 hours, and precipitating factors should be treated. When pseudo-obstruction does not settle with waitful watching, prokinetic agents and/or colonoscopic decompression can be tried. When there is a risk of impending perforation of the caecum from massive colonic dilatation and colonic ischaemia, it should be dealt with by caecostomy or hemicolectomy. In spite of available medical and surgical interventions, the outcome remains poor.