A 34-year-old man with ulcerative colitis (UC) presented to a peripheral hospital with bloody diarrhea. He had previously required infliximab but had stopped biologic therapy 5 years earlier. Workup included a colonoscopy with retroflexion, and he developed abdominal pain and fever after procedure. He was brought to Victoria, British Colombia, where computed tomography in the abdomen showed a complex disorganized perirectal collection of gas and fluid. Surgery recommended colectomy; however, the patient declined. Flexible sigmoidoscopy showed a 6-mm anterior defect and moderately severe UC (a). An endoluminal vacuum-assisted closure (EVAC) device was inserted opposite the perforation site (a). With broad-spectrum antibiotics, total parenteral nutrition, and EVAC change every 3 days, C-reactive protein fell rapidly. Flexible sigmoidoscopy on day 3 (b) and day 7 (c) showed significant improvement in the defect, and infliximab biologic therapy was reinitiated. Computed tomography and repeat flexible sigmoidoscopy showed resolution of the abscess and perforation, and he was transitioned to an enteral diet and discharged home with outpatient infliximab therapy. EVAC has been used to treat upper and lower gastrointestinal defects, most commonly in anastomotic leaks. To the best of our knowledge, this represents the first successful treatment of a rectal perforation with EVAC in the setting of active UC (Informed consent was obtained from the patient to publish these images.)