A 75-year-old male with a history of gastroesophageal reflux disease presented to an outside hospital after a syncopal episode. Prior to arrival, he had three months of vague epigastric discomfort unrelated to eating, one month of progressive fatigue and dyspnea, and one week history of melena. On exam, his abdomen was soft and non-tender with guaiac positive stools. Laboratory values revealed Hgb of 6.9 g/dL (MCV 85 fL, RDW 25%). Esophagogastroduodenoscopy (EGD) and colonoscopy were normal without a bleeding source identified. Small bowel follow through was also normal. He was discharged on pantoprazole after symptomatic improvement with blood transfusions. One month later, he was admitted to our hospital with worsened fatigue, dyspnea on exertion, and recurrent melena. Laboratory assessment revealed a Hgb of 6.0 g/dL (MCV 83 fL, RDW 24%). Repeat EGD and colonoscopy as well as enteroscopy were all normal. A video capsule endoscopy was performed revealing several ulcerated masses in the proximal jejunum including one with a fresh blood clot. As these lesions were within reach, push enteroscopy was repeated and the ulcerations visualized. Biopsies were consistent with large B-cell lymphoma resulting in proximal jejunal resection with primary anastamosis. Discussion: Gastrointestinal (GI) bleeding with its point of origin outside the reach of EGD and colonoscopy represents an extraordinary diagnostic and therapeutic challenge. In approximately 5% of cases, the bleeding source is located in the small bowel. Optimal diagnostic approach to identify small bowel lesions is unknown. After a non-diagnostic EGD and colonoscopy, push-enteroscopy is often considered the next intervention. However, the procedure can be technically difficult, limited by intestinal motility and looping, with potential complications of post-procedure abdominal pain, intussusception, and pancreatitis. Also, only a limited portion of the proximal jejunum can be examined. Several randomized, controlled trials have shown capsule endoscopy (CE) to have a higher diagnostic yield for obscure GI bleeding compared to enteroscopy. In our patient, the malignancy was initially missed by enteroscopy but successfully visualized once guided by CE findings. Targeted enteroscopy then led to tissue diagnosis and assisted in operative planning. Given its higher diagnostic sensitivity, it should be considered before push enteroscopy for diagnostic work-up of patients with obscure blood loss.