Imatinib-associated acute liver failure (ALF) is rare. Urgent liver transplantation after treatment of a gastrointestinal stromal tumor (GIST) requires balancing immediate mortality against oncologic risk.

A 34-year-old woman developed hepatocellular injury after 8 months of adjuvant imatinib (400 mg/day) following resection of a 6-cm small-bowel gastrointestinal stromal tumor. Imatinib was her only medication; no other drugs, herbal remedies, supplements, or hormonal treatments were used. Despite withdrawal and supportive care, she developed severe coagulopathy and grade IV hepatic encephalopathy. Major alternative causes were excluded; a Roussel Uclaf Causality Assessment Method score of 5 indicated possible causality. She fulfilled Clichy-Villejuif criteria and underwent urgent deceased-donor liver transplantation. Explant histology showed extensive hepatocellular necrosis. At 1 year, graft function was normal without tumor recurrence.

Published transplant experience consists mainly of isolated cases in chronic myeloid leukemia. Reported outcomes are heterogeneous, with limited follow-up and uncertain causal attribution in some cases.

A history of resected GIST should not, by itself, exclude urgent transplantation for progressive imatinib-associated ALF. Individualized assessment must weigh the immediate survival benefit against tumor recurrence risk and the feasibility of subsequent oncologic treatment and surveillance.