CASE PRESENTATION: A 26-year-old male with a history of type I diabetes presented with vomiting and abdominal pain of 1 day. Exam was remarkable for BP of 93/60 mm Hg & HR of 106. Patient was cachectic & in distress, abdomen was distended with diffuse tenderness. Labs revealed Hb of 8, leucocytosis of 13000 and lactate of 3.6. IV fluid bolus & antibiotics were started. 6 hours later he had emesis of black fluid with development of shock requiring vasopressors, intubation for acute respiratory failure and intensive care. Abdominal X-ray showed a giant lucency, thought to be the distended stomach. NG tube inserted returned 2.4 liters of black fluid. CT abdomen showed a distended gastric & esophageal lumen with a transition point between the 2nd and 3rd part of duodenum. EGD showed deep ulcerations over the stomach and eschar formation. Upper GI series confirmed SMA syndrome. As patient continued to be in septic shock ,surgery was deferred. Explorative laparotomy done on Day 9 of admission, ended in total gastrectomy and esophago-jejunostomy & a feeding jejunostomy. Post procedure patient had a prolonged recovery.