S4935 Constipation to Colectomy: An Unusual Case of Ulcerative Colitis

Introduction: Ulcerative colitis (UC) is a chronic, immune-mediated inflammatory disease, most commonly presenting in young adults with symptoms of bloody diarrhea, urgency, and tenesmus. Disease onset typically occurs in a bimodal distribution stronger age 15-30 years versus 50-70 years. Onset after age 70 is much less frequent. While the classic presentation includes bloody diarrhea, constipation is an uncommon primary symptom (up to 12%–20% of UC patients). It is rarely the main presenting complaint, especially in adults. Case Description/Methods: A 77-year-old Black woman with a history of chronic constipation presented with abdominal pain, bloating, weakness and dizziness following initiation of colonoscopy prep. Physical exam revealed dry mucous membranes and abdominal distention with tenderness. Admission labs were notable for leukocytosis, elevated C-reactive protein, lactic acidosis, acute kidney injury, and severe electrolyte derangements. Computed tomography of the abdomen and pelvis showed a distended colon with wall thickening consistent with colitis. Once the patient was stabilized to tolerate endoscopy, findings included anal stenosis and severe inflammation with diffuse colonic ulcerations, concerning for acute severe UC. Despite aggressive medical management (intravenous antibiotics and endoscopic decompression), she had persistent abdominal distention and pain. Repeat computed tomography revealed toxic megacolon, with colonic distention >10 cm. Given risk of perforation, she underwent emergent total colectomy with colostomy. Histopathology confirmed severe active colitis with features consistent with UC. The patient’s bowel function slowly returned via stoma, with eventual full recovery. Discussion: This case is an atypical presentation of UC in an elderly patient, where severe constipation masked underlying UC until the development of life-threatening complications. The ACG emphasizes that prompt recognition and diagnosis of UC are critical to prevent poor outcomes, yet constipation as a presenting feature may delay diagnosis, particularly in older adults. Studies suggest constipation in UC may be associated with rectal fibrosis and altered motility. While more common in limited disease, these can occur in extensive colitis. Clinicians should maintain a high index of suspicion for UC in elderly patients presenting with new or worsening constipation, especially when accompanied by systemic symptoms, to facilitate timely intervention and reduce morbidity.