INTRODUCTION: Capecitabine is a fluoropyrimidine chemotherapy agent used in the treatment of colorectal cancer. Gastrointestinal side effects are common, including diarrhea, nausea, vomiting, abdominal pain, severe hepatic impairment, and decreased appetite. Here we report a case of Capecitabine-induced ileitis with severe diarrhea leading to hypovolemic shock and acute kidney injury. The patient was admitted to the intensive care unit (ICU) twice during hospitalization and required cessation of capecitabine. CASE DESCRIPTION/METHODS: Our patient is an 82-year-old male with a history of prostate cancer now with stage IIA rectal adenocarcinoma who was started on Capecitabine neoadjuvant chemotherapy without radiation due to previous pelvic radiotherapy for the prostate cancer. He tolerated the first treatment cycle without any side effects. At the beginning of the 2nd cycle, he reported eight watery non-bloody bowel movements a day. CT abdomen showed wall thickening of multiple loops of the distal small bowel. He was admitted to the ICU, started on vasopressor therapy and broad-spectrum antibiotics, but diarrhea persisted. Physical exam showed mild diffuse abdominal tenderness. Laboratory studies were notable for elevated creatinine but stool culture, ova and parasites, and Clostridium difficile PCR were negative. Antibiotics were stopped and loperamide was started without significant improvement. Gastroenterology was consulted and colonoscopy showed linear ulcers at terminal ileum and ulceration at ileocecal valve - pathology showed active ileitis with ulceration. Diarrhea improved with supportive management and cessation of Capecitabine. DISCUSSION: Although Capecitabine's side effects are mostly well tolerated, they can occasionally lead to prolonged hospitalization and even ICU admission. Capecitabine is not a cytotoxic drug in itself, it is absorbed from the intestine and metabolized in the liver then in the tumor cells by three-step enzymatic cascade to be converted to 5-FU. Capecitabine-induced ileitis has been reported in the literature and was diagnosed by a combination of symptoms, CT scan, colonoscopy, and/or histopathology. The mechanism is reported to be due to the susceptibility of the intestinal vascular endothelium to 5-FU by the generation of free radicals which may lead to a hypercoagulable state. In summary, treating physicians should be aware of this critical side effect and intervene early when diarrhea is reported.