Purpose <p>Strangulated bowel obstruction is a critical condition requiring emergency surgery. This study investigated the clinical parameters of patients undergoing emergency surgery for strangulated and non-strangulated bowel obstructions and identified the predictive factors for intestinal ischemia.</p> Methods <p>This retrospective review included 270 patients who underwent surgery for bowel obstruction. The clinical and operative factors were analyzed to determine the predictive factors for intestinal ischemia. A novel predictive scoring system was developed based on significant parameters identified by a multivariate analysis.</p> Results <p>Among patients with strangulated bowel obstruction, independent predictors for the need for intestinal resection were massive ascites, computed tomography value ≤ 50 Hounsfield units, lactate levels ≥ 30&#xa0;mg/dL, and neutrophil–lymphocyte ratio ≥ 8.5. A novel predictive score was developed using these four parameters. Patients with a score of 0 did not require intestinal resection because of strangulation. Fifteen patients, with a score of 7, developed irreversible ischemia and required intestinal resection.</p> Conclusions <p>A predictive score incorporating ascites, computed tomography values, lactate levels, and neutrophil–lymphocyte ratio effectively stratified patients with strangulated bowel obstruction, aiding early diagnosis and risk stratification.</p>