A 65-year-old man presented to the ED for evaluation of a 1-week history of intermittent, exertional syncope and coffee ground emesis. His medical history was significant for hypertension, peripheral vascular disease, hyperlipidemia, and peptic ulcer disease. Although his social history was positive for alcohol use and abuse, the patient stated that he had not consumed any alcoholic beverages since the onset of nausea and vomiting. A review of the patient's systems was positive for lightheadedness upon standing and for palpitations. He had no prior history of melena, hematochezia, or syncope, but did report a previous history of upper gastrointestinal (GI) bleeding due to peptic ulcer disease and alcohol abuse. The patient's vital signs at presentation were: blood pressure (BP), 114/74 mm Hg; heart rate, 112 beats/min; respiratory rate, 15 breaths/min; and temperature, 97.7°F. Oxygen saturation was 97% on room air. On examination, the patient was conversant and oriented. He had dried blood around his mouth and chin from vomiting and appeared ill but nontoxic. His mucous membranes were pale. The cardiopulmonary examination was remarkable for tachycardia; however, the patient's extremities were warm and his capillary refill time was normal. The rectal examination was notable for melenic stool, which was guaiac positive. During the patient's course in the ED, he passed a large, melenic stool. The remainder of the physical examination was normal. The chest X-ray was normal, but the electrocardiogram demonstrated sinus tachycardia. Laboratory studies were remarkable for the following: In this case presentation of a 65-year-old man who presented to the ED for evaluation of a 1-week history of intermittent coffee-ground emesis and syncope, the authors review the literature about a rare, but potentially fatal diagnosis.