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A 29-year-old patient was admitted to our hospi tal with hematemesis, hematochezia and abdominal pain. He was affected by polycythemia (basal hemoglobin level: 18.5 g/dL) and referred cocaine abuse. Physical examination showed mild diffuse abdominal tenderness, hypotension, tachycardia and postural changes. Laboratory data documented a severe anemic condition (hemoglobin: lO g/dL). Therefore, an upper gastrointestinal endoscopy was performed showing blood clots in the fundic area and a gastric ulcer with non bleeding visible vessel, undergone to injection therapy (epinephrine 1:10000, total amount 8 ml); in addition, mucosa of the distal duodenum appeared frankly ischemic. A colonoscopy was negative for mucosal lesions but revealed the presence of red blood. Subsequently, an arteriogram of mesenteric vessels documented occlusion of the superior mesenteric artery. Therefore, patient underwent surgical intervention with extensive jejunal and limited ileal resection. We present a case of acute intestinal ischemia in a young man with polycytemia and cocaine abuse. The combination of the above conditions is rare. Nevertheless, mesenteric ischemia should be considered in the differential diagnosis of abdominal pain syndrome in patients with cocaine abuse.