Acute mesenteric ischemia is always an emergency and is associated with a high mortality rate. It predominantly affects elderly people with an underlying cardiovascular disorder. Although most of the cases present with sudden onset of abdominal pain, atypical symptoms including mental confusion, bacteremia, and gastrointestinal (GI) bleeding may be the foremost presentation.1 GI bleeding may be the dominant symptom in rare cases and almost always presents as occult or overt lower GI hemorrhage.

We report the case of a 48-year-old man who presented to the Emergency Department (ED) of a university teaching hospital in northern India with the complaints of progressive abdominal pain and hematemesis.

Our reasons for highlighting this case are:

• The unusual presentation of an often clinically subtle disease made this case especially challenging to diagnose.

• The presence of confounding factors and “red herrings” caused further delay in the diagnosis of mesenteric ischemia.

• Mesenteric ischemia continues to remain a provisional diagnosis of low suspicion in a middle aged individual with abdominal pain and upper gastrointestinal hemorrhage presenting to the ED.

Keywords: Hematemesis; Gastrointestinal hemorrhage; Mesenteric ischemia.