INTRODUCTION: Outcomes of emergency bowel surgery are dependent on the structural factors of an institute and quality of care to a single patient along with disease process and pre-existing condition. The purpose of this study was to determine the mortality of emergency bowel surgery at a tertiary care center in Pakistan, the review processes involved in the care of patients, and to compare these variables with the first patient report of the National Emergency Laparotomy Audit (NELA). METHODS: A retrospective audit of patients undergoing emergency bowel surgery at Aga Khan University Hospital (AKUH), Karachi, from November 2013 to October 2014. Comparative analysis was done with the NELA report to determine the areas requiring improvement. RESULTS: A total of 74 patients underwent emergency bowel surgery. Twenty-four patients having penetrating trauma were excluded due to different pathophysiology and outcome. When compared with the NELA report, the patients were younger and predominantly male with nearly the same spectrum of disease, but mortality rate was twice that when compared to NELA (24% vs 11%). Comparative analysis showed that care at AKUH was significantly lacking in proper preoperative risk assessment and documentation, booking to operating room timing, intraoperative goal directed fluid therapy using cardiac output monitoring, and postoperative provision of intensive care to the highest risk patients. CONCLUSIONS: This study helped to understand deficiencies in the care of patients undergoing emergency bowel surgery and alarmingly poor outcomes in a very systematic manner. We plan to do interventions in deficient areas to improve patient care and outcomes with limited resources of a developing country