Introduction: Ischemic proctitis is a rare pathological condition. Most cases of ischemic proctitis reported are secondary to acute myocardial infarction (MI), septic shock, radiotherapy, aortoiliac surgery, and vasculitis. The rich vascular supply from inferior mesenteric, internal iliac, and internal pudendal arteries with collaterals preserves blood supply even in low cardiac output states, and the rectum is usually spared from ischemic changes. In fact, ischemic proctitis is found in only 2-5 of 10,000 cases of lower GI bleed. Although a CT scan can suggest the diagnosis, colonoscopy remains the gold standard in diagnosing and determining the extent of ischemic change. We present a rare case of ischemic proctitis in a middle-aged male due to cardiogenic shock despite institution of intra-aortic balloon pump (IABP), vasopressor support, and extracorporeal membrane oxygenation (ECMO). A 51-year-old male without significant medical history presented with worsening dyspnea on exertion for 1 week. On admission, the patient was found to have an acute anterior wall MI. He was found to have right and left coronary disease and later developed complete heart block along with cardiogenic shock. He was intubated and started on vasopressors. Blood pressure was initially supported by dobutamine, milrinone, and levophed but IABP was ultimately required. Subsequently, the patient developed hypoxemic respiratory failure and veno-arterial ECMO was initiated. He subsequently developed hematochezia and a significant drop in his hematocrit was noted. ECMO flows were also noted to be low and, in order to sustain them, patient required transfusions, fluid support, and albumin. As patient’s hemoglobin was dropping further, heparin was discontinued and urgent colonoscopy performed. Colonoscopy demonstrated friable mucosa with multiple superficial ulcers in the rectum. Changes noted were suspicious for ischemic proctitis (Figure 1). Rectal biopsies confirmed the diagnosis of ischemic proctitis (Figure 2). Patient was managed conservatively with supportive measures and control of bleeding was achieved. During the course of his hospitalization, patient subsequently developed DIC and expired due to septic shock. As our case demonstrates, although a rare entity, ischemic proctitis is an important potential diagnosis in the setting of ECMO.Figure: s.