Ischemic enteritis (IE) is defined as hypoperfusion of the mesenteric vessels to the small bowels and is a rare diagnosis due to rich collateral vasculature. IE typically presents with nausea, abdominal pain, vomiting and rarely presents with melena. Risk factors include hypertension, diabetes, ischemic heart disease and atherosclerosis. IE is difficult to diagnose as no set diagnostic criteria exists and endoscopiy is often not the first line of work up for patients who present with these symptoms. We report an atypical presentation of ischemic enteritis, which has rarely been documented endoscopically. A 78-year old male presented with chest pain and was found to have a myocardial infarction. His medical history included hypertension, pulmonary hypertension and right-sided heart failure. His hospital course was complicated by acute respiratory failure, secondary to cardiogenic shock, requiring intubation. Over 24 hours, he developed maroon colored stools with hemoglobin dropping from 7.6 g/dL to 6.6 g/dL, prompting endoscopic evaluation. Colonoscopy revealed blood clots in the terminal ileum, cecum and ascending colon with a patchy, erosive appearance concerning for ischemic colitis. An esophagogastroduodenoscopy revealed stress gastropathy. Neither upper or lower endoscopy identified a source of bleeding. Small bowel capsule endoscopy showed ulcerations in the proximal small bowel. Single balloon enteroscopy revealed a large, circumferential ulceration in the jejunum, 40 centimeters in length, shallow, irregular and without heaped borders. Pathology of the biopsied ulcer revealed fragments of inflamed granulation tissue with no overt microorganisms, viral changes, granulomas or malignancy seen. The ulceration was likely a result of ischemic enteritis, given the macroscopic and microscopic findings and a clinical diagnosis of ischemic cardiomyopathy. Endoscopic therapy was not done, as the bleeding was noted to occur in a multi-focal distribution. Despite aggresive medical management, the patient failed numerous weaning trials, had a progressive decline in nutritional status and was transitioned to hospice care.Figure 1Figure 2Ischemic enteritis is a rare condition and the presentation as an obscure-overt GI bleed is of greater rarity given that nausea, vomiting and abdominal pain are the most common symptoms. Endoscopic findings include circumferential stenosis with thickening of the walls and histologic characteristics include inflammatory cell infiltration. A majority of patients with IE develop multi-organ failure, sepsis and ultimately succumb to death. Thus, when encountering a patient with risk factors for ischemia in the setting of obscure overt bleeding, IE should be highly considered. In this case, balloon enteroscopy was vital in diagnosis and also captured images infrequently reported in the medical literature.