S4945 Disseminated Intravascular Coagulation: An Unexpected Signpost to Ulcerative Colitis

Introduction: Ulcerative colitis (UC) is a chronic inflammatory bowel disease marked by recurrent episodes of inflammation affecting the colonic mucosa. Diagnosis relies heavily on clinical presentation, endoscopic evaluation, and histologic examination. UC is associated with a range of extra-intestinal manifestations that can involve multiple organ systems and exhibit autoimmune characteristics, complicating the diagnostic process. Case Description/Methods: We report a case of a 25-year-old man who presented with abdominal pain and bloody diarrhea, initially treated as infectious colitis with oral antibiotics, only to come back 10 days later with worsening symptoms. Initial blood work was unremarkable on admission. Further laboratory testing revealed an elevated C-reactive protein, stool calprotectin, and lactoferrin. An extensive infectious work up was done and came back negative. During his stay, the patient developed thrombocytopenia and gross hematuria, then his condition rapidly deteriorated, developing pancytopenia, elevated D-dimer and international normalized ratio, and a decreased fibrinogen level suggesting a disseminated intravascular coagulation (DIC). Other hemolytic and inflammatory pathologies were ruled out. A repeat computed tomography scan revealed pancolitis significantly worse than the prior imaging. Subsequent colonoscopy revealed diffusely ulcerated, friable, congested, and edematous mucosa extending from the rectum to the cecum, with spontaneous mucosal bleeding and exudate, consistent with severe colonic disease. Biopsies showed severely active chronic colitis with crypt distortion, acute cryptitis, crypt abscesses, regenerative glandular changes, and detached fragments of fibrinopurulent exudates, consistent with ulcerative colitis. The patient’s clinical status rapidly improved after steroids therapy. Discussion: The patient's presentation with DIC as an initial manifestation of UC deviates from the typical disease course. DIC is a life-threatening condition, its occurrence in IBD is rare and usually linked to severe disease. The presentation of DIC as an initial manifestation of IBD, as observed in this case, is exceptionally rare. This scenario emphasizes the importance of maintaining a broad differential diagnosis and considering IBD in cases of acute bloody diarrhea, even in patients without a prior history of gastrointestinal disorders. It also highlights the need for vigilant monitoring of coagulation parameters in patients with severe ulcerative colitis, even on initial presentation.