Very Early-Onset Ulcerative Colitis Manifesting as Acute Rectal Prolapse and Persistent Hematochezia in a Three-Year-Old Child: An Observational Analytic Case Study of Diagnostic Trajectory and Multimodal Intervention

Abstract

Background: Very early-onset ulcerative colitis (VEO-UC), diagnosed before six years of age, is uncommon and often presents atypically. In toddlers, severe proctitis with tenesmus can weaken pelvic floor support and cause full-thickness rectal prolapse, which can mimic solitary rectal ulcer syndrome, cow's milk protein allergy or primary rectal prolapse.

Objective: To describe the diagnostic course, treatment and six-month outcome of a toddler with VEO-UC presenting with full-thickness rectal prolapse.

Methods: A boy aged 3 years 3 months presented to K.R.M.T. Wongsonegoro Regional Hospital with persistent mucoid hematochezia, a 1-kg weight loss and full-thickness rectal mucosal prolapse. He was followed over seven epochs from baseline (T0) to month 6 (T6). Work-up comprised colonoscopy with biopsy, abdominal ultrasonography and serial inflammatory biomarkers. Treatment was a Thiersch anal cerclage with oral mesalazine induction (60–80 mg/kg/day).

Results: Colonoscopy showed continuous hyperemia and multiple 2–6 mm ulcers with fibrinous exudate in the rectosigmoid and descending colon; ultrasonography found no mass or lymphadenopathy. After cerclage on hospital day 2 and mesalazine induction, the Pediatric Ulcerative Colitis Activity Index (PUCAI) fell from 45 at T0 to 0 at T5–T6 . Hematochezia had resolved by week 4. Fecal calprotectin declined from 880 to 35 μg/g (−96.0%), and weight rose from 13.0 to 14.6 kg (+12.3%). The prolapse did not recur.

Conclusion: Full-thickness rectal prolapse in early childhood can be the first sign of VEO-UC. Prompt colonoscopy and combined medical and surgical management were followed by anatomical stabilization and mucosal healing in this patient.