INTRODUCTION: Colorectal cancer (CRC), the third most prevalent malignancy globally, can present with complications such as bleeding, obstruction, and, less commonly, perforation. These complications are associated with significant morbidity and mortality, demanding timely recognition and intervention. Unusual initial symptoms can obscure the clinical picture, delaying diagnosis, and treatment. CASE PRESENTATION: We report a 50-year-old male with a history of rectosigmoid adenocarcinoma treated with surgery and chemoradiotherapy, presenting with atypical symptoms of intractable hiccups, watery diarrhea, and vomiting. Initial imaging indicated an ileostomy site perforation with signs of ischemic colitis. Exploratory laparotomy revealed a perforation at the splenic flexure, ischemic colitis, and a stenosing rectosigmoid tumor. A total colectomy with end ileostomy was performed, leading to resolution of symptoms and stabilization of the patient. CONCLUSION: This case emphasizes the importance of recognizing atypical presentations of CRC and its complications. Prompt and comprehensive diagnostic evaluations followed by appropriate surgical intervention can improve outcomes and prevent further deterioration. Early recognition of unusual symptoms is critical in guiding effective management.