Authors: Mohammed Ahmed Al-Matwi , Jood Hazem Mahmoud Hamdan , Hissa Al Kuwari , Abdulrahman AlQaderi , Kawther Bader Qarqoor , Kawthar Ghaleb Alaali , Fatema J. Alasheeri , Zahra Jamal Hubail , Joshua Charly , Gufran Reda Al-Dagdoog , Sara Saeed Mohamed , Noor Hameed Meftah ,

Abstract

Background: New-onset constipation in middle-aged and older adults can be an early and sometimes the only presenting sign of colorectal malignancy. This risk is particularly relevant in populations with low screening uptake (e.g., in regions where national screening programs are recent or underutilized). Timely recognition of alarm features and appropriate imaging are important to diagnose obstruction and stage the disease.

Case presentation: A 54-year-old Saudi man without chronic illnesses presented with a 2-week history of progressive constipation and abdominal distension, and three days of diffuse abdominal pain with recurrent vomiting. He reported no flatus for 2 days and no stool for four days. He denied weight loss or rectal bleeding. Examination showed a markedly distended but soft abdomen with tenderness in the right lower quadrant; bowel sounds were hypoactive. The digital rectal exam was normal. Laboratory tests revealed leukocytosis (white blood cell count 11.4 × 109/l; reference range 4.5-11.0 × 109/l); renal function and electrolytes were normal. A supine abdominal radiograph demonstrated multiple dilated bowel loops with air-fluid levels and no
distal colonic gas, consistent with large-bowel obstruction. Contrast-enhanced computed tomography identified a circumferential sigmoid mass (~3.7 × 3.0 cm) with an abrupt transition point and marked proximal colonic and small-bowel dilation. No mesenteric stranding, ascites, or free air was present; multiple hypodense liver lesions (largest ~2.5 cm) and enlarged iliac nodes indicated metastatic disease. No hernia was seen. Given the obstructive symptoms and stage IV disease, the patient underwent a palliative diverting colostomy. Postoperatively, he recovered uneventfully and was referred for oncology and palliative care.

Conclusion: New or worsening constipation in adults over 50 should prompt early evaluation for colorectal obstruction. Cross-sectional imaging is essential when obstruction is suspected, and management must be tailored to the disease stage. In metastatic cases, palliative decompression (e.g., stoma formation) can relieve symptoms and improve quality of life. Increased awareness of constipation as an alarm symptom and better colorectal cancer screening uptake are important to facilitate earlier diagnosis.

Keywords: Colon cancer, End-stage malignancy, Metastases, Constipation, Intestinal obstruction, Sigmoid mass.