Objective: To comparatively analyze the clinical efficacy and prognostic factors of conservative treatment and surgical treatment for acute intestinal obstruction in the elderly. Methods: 84 elderly patients with acute intestinal obstruction admitted to our hospital from February 2025 to February 2026 were selected and divided into a conservative group and a surgical group according to the actual treatment methods, with 42 cases in each group. The conservative group adopted conventional conservative methods such as fasting and water fasting, gastrointestinal decompression, fluid replenishment support, anti-infection, and enema for defecation; the surgical group performed corresponding surgical operations such as intestinal adhesion lysis, intestinal resection and anastomosis based on the specific cause of the patient’s obstruction. The time to relieve abdominal pain and distension, the recovery time of anal discharge, and the total length of hospitalization of the two groups of patients were recorded. Various complications that occurred during the treatment were counted. Information such as the patient’s age, underlying disease status, duration of onset of obstruction, type of obstruction, etc., was also collected to compare and analyze the relevant factors affecting the patient’s prognosis. Results: The abdominal pain, abdominal distension, and hospitalization time of patients in the surgical group were significantly shorter than those in the conservative group (P < 0.05); however, the probability of complications such as postoperative lung infection and incision infection in the surgical group was higher than that in the conservative group, but there was no significant difference in the overall complication rate between the two groups (P > 0.05). Through clinical observation, it can be found that older patients, those with multiple underlying diseases, those with an onset time of more than two days, and those with strangulating intestinal obstruction generally have worse recovery results in the later period. Conclusion: When clinically treating elderly patients with acute intestinal obstruction, it is necessary first to distinguish the specific type of obstruction. For simple adhesive intestinal obstruction, conservative treatment can be tried first. Once strangulating intestinal obstruction is diagnosed or conservative treatment is ineffective, surgery must be performed in time. In daily diagnosis and treatment, more attention should be paid to patients who are elderly, have many underlying diseases, and have been ill for a long time, and intervene as early as possible to improve the patient’s recovery.