Background Limited data exist examining the use of fecal diversion in combatants from modern armed conflicts. Characterization of factors leading to colostomy creation is an initial step toward optimizing and individualizing combat casualty care. Methods A retrospective review of the US Department of Defense Trauma Registry database was performed for all US and coalition troops with colorectal injuries sustained during combat operations in Iraq and Afghanistan over 8 years. Colostomy rate, anatomic injury location, mechanism of injury, demographic data, and initial physiologic parameters were examined. Univariate and multivariate analyses were conducted. Results We identified 867 coalition military personnel with colorectal injuries. The overall colostomy rate was 37%. Rectal injuries had the highest diversion rate (56%), followed by left-sided (41%) and right-sided (20%) locations (P <.0001). Those with gunshot wounds (GSW) underwent diversion more often than blast injuries (43% vs 31% respectively, P <.0008). Injury Severity Score ≤16 (41% vs 30%; P =.0018) and damage control surgery (DCS; 48.2% vs 31.4%; P <.0001) were associated with higher diversion rates. On multivariate analysis, significant predictors for colostomy creation were injury location: Rectal versus left colon (odds ratio [OR], 2.2), rectal versus right colon (OR, 7.5), left versus right colon (OR, 3.4), GSW (OR, 2.0), ISS ≤ 16 (OR, 1.7), and DCS (OR, 1.6). Conclusion In this exploratory study of 320 combat-related colostomies, distal colon and rectal injuries continue to be diverted at higher rates independent of other comorbidities. Additional outcomes-directed research is needed to determine whether such operative management is beneficial in all patients.