Extensive Colonic Pseudopolyposis Leading to Protein-Losing Enteropathy and Severe Hypoalbuminemia With Refractory Ulcerative Colitis.

Extensive pseudopolyposis in ulcerative colitis (UC) is rare and can lead to protein-losing enteropathy (PLE) with severe hypoalbuminemia. We report an 18-year-old male with steroid-dependent UC complicated by extensive colonic pseudopolyposis causing PLE. This represents one of the few reported cases of PLE secondary to extensive colonic pseudopolyposis in UC. He presented with profound hypoalbuminemia reaching a nadir of 1.0-1.5 g/dL, malnutrition, iron-deficiency anemia, and deep-vein thrombosis. Colonoscopy and imaging revealed dense pseudopolyps from the proximal sigmoid to the cecum, with minimal inflammation. Renal and hepatic causes of protein loss were excluded through routine urinalysis, the absence of proteinuria, normal creatinine levels, normal liver enzymes, and unremarkable renal and hepatic imaging. Although formal quantitative PLE testing, such as α-1 antitrypsin clearance, was unavailable at our center, the persistent severe hypoalbuminemia, minimal inflammatory activity, and exclusion of alternative etiologies strongly supported a diagnosis of pseudopolyposis-associated PLE. Management included multiple biologics, steroid tapering, total parenteral nutrition, and anticoagulation; colectomy was declined. Clinicians should maintain a high index of suspicion for PLE in UC patients with extensive pseudopolyposis and hypoalbuminemia disproportionate to the degree of inflammation.