INTRODUCTION: Individuals aged >60 years contribute to 10%-15% of inflammatory bowel disease diagnoses with merely 10% of them being over 80 years of age. Older-onset ulcerative colitis (UC) is more common than Crohn's disease, with a male preponderance. Compared to younger patients, UC in the elderly manifests more as proctitis, has a subtler presentation with lesser bleeding, diarrhea, and abdominal pain, and a lower risk of relapse, but with increased severity. Till date, literature regarding UC in the octogenarian age group is limited to a handful of case reports. CASE DESCRIPTION/METHODS: An 81-year-old-male, non-smoker, with a history of coronary artery disease and family history significant for systemic lupus erythematosus, presented with moderate to severe, dull, periumbilical abdominal pain of one-month duration, associated with mucoid diarrhea, intermittent high-grade fever, anorexia, and unintentional weight loss. He denied any nausea, vomiting, blood in vomit or stools, icterus or pruritus. He did not report any history of high-risk behavior or recent travel. His examination was unremarkable except periumbilical and diffuse lower abdominal tenderness. Laboratory evaluation was notable for leucocytosis (13.5 K/ul), hyponatremia (128 mEq/L) and hypokalemia (3.1 mEq/L). U/S abdomen showed intestinal distension and a trial of opioid receptor agonists and probiotics was initiated for a probable diagnosis of irritable bowel syndrome, which failed to show clinical improvement. Treatment with broad-spectrum antibiotics, based on CT findings suggestive of colitis, led to partial symptomatic relief. Colonoscopy was performed following a recurrence of symptoms that revealed multiple areas of ulcerations and a biopsy confirmed the diagnosis of UC. The patient received guideline-directed medical therapy with 5-aminosalicylates and corticosteroids, which led to clinical improvement, and since then, the patient has been in remission. DISCUSSION: The unique pathophysiology, clinical manifestations and disease course of UC in the elderly add to its diagnostic challenge. Additionally, the scarcity of literature regarding treatment guidelines and lack of clarity of appropriate clinical endpoints (objective vs.symptom control) limits evidence-based decision in this population with a higher hospitalization and mortality rate. Consequently, a high degree of suspicion needs to be maintained in the aging population presenting with clinical features of colitis to ensure prompt treatment and limit complications.