Purpose: Acute colonic pseudo-obstruction (ACP) is a life-threatening, rare condition of non-mechanical colon dilatation that could result in bowel ischemia and perforation. The aetiology is relatively unknown but includes elderly highly comorbid patients, decreased parasympathetic activity, certain medications, chemoradiotherapy and recent surgery. There is limited research data on ACP following reversal of ileostomy after ultra-low anterior resections (ULAR), thus this systematic review encompassed all types of bowel surgery. Methods: A comprehensive literature search of relevant articles was conducted using EMBASE, Medline, PubMed, Cochrane and Scopus databases. Two cases of ACP following ileostomy reversal after ULAR for rectal cancer were reported from this rural institution. Results: 522 studies were screened of which 5 case reports were included. Two case series (6 patients) and the two patients from this rural institution developed ACP following reversal of ileostomy post-ULAR with potential causes being prolonged >6months time to reversal from initial surgery causing prolonged colonic mucosal inflammation and reduced wall contractile strength. Anastomotic leak and chemoradiotherapy were other considerations. One of the rural patients developed right colon ischemia and perforation needing urgent laparotomy, right hemicolectomy and formation of end ileostomy and mucous fistula. Conservative treatment included aperients, enemas, flatus tube, bedside or endoscopic decompression and neostigmine. Conclusion: Early recognition is vital to treat ACP with medical therapy and decompression to prevent bowel ischemia and perforation. More research is required to better characterize the aetiology, incidence and management of this rare condition.