MGMT. OF COMPLEX CASES IN GI ONCOLOGY Therapeutic Challenges in the Management of Bleeding Duodenal Gastrointestinal Stromal Tumor: a Case Report and Review of Literature Gautham Krishnamurthy 1 & Harjeet Singh 1 & Vishal Sharma 2 & Ajay Savlania 1 & Rakesh Kumar Vasishta 3 # Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract Introduction Duodenum is an uncommon site for the gastrointestinal stromal tumors (GISTs). Though the principles of man- agement are the same of that elsewhere in the gastrointestinal tract, the anatomical complexity poses challenges in deciding the most appropriate treatment. A bleeding GIST further compounds the difficulty in managing such patients. Case Report A twenty-eight-year-old female presented with bleeding duodenal lesion secondary to mucosal ulceration. Imaging confirmed large heterogeneous lesion arising from the second part of duodenum. Surgery was planned in view of persistent blood transfusion requirement. Pancreaticoduodenectomy was done and the patient had an uneventful postoperative period. Discussion Review of literature of duodenal GIST especially regarding the tough decisions that have to be made in the diagnosis and management of bleeding lesions has been done. Conclusion The availability of various options in addressing bleeding duodenal GIST should make the surgeon choose the best modality for the patient weighing the pros and cons of each modality. Keywords Gastrointestinal stromal tumor . Duodenum . Imatinib . Pancreaticoduodenectomy . Bleeding Introduction Gastrointestinal stromal tumor (GIST) commonly affects the stomach with rare involvement of the duodenum [1]. Bleeding is the most common presentation of these tumors [2]. The patient status, magnitude of bleed, location of tumor, tumor characteristics, and the availability of resources dictate the management in bleeding lesions [3–5]. We report a case of bleeding duodenal GIST along with the various challenges posed. Review of literature on the management options of a bleeding duodenal GIST has been discussed. Case Report A 28-year-old female was referred to our surgical outpatient department with the complaints of melena and easy fatigability for 3 weeks. On evaluation elsewhere for the above complaints, she was found to have ulcerated lesion with everted margin in the medial wall of third part of duodenum. The biopsy of the lesion was suggestive of chronic inflammation. Patient was stabilized and referred on oral pantoprazole 80 mg per day. On clinical examination, she was pale with pulse rate of 90/ min. A well-defined firm mass of size 5*5 cm was palpable in the right hypochondrium. Per rectal examination confirmed melena. Ultrasound showed a large heterogeneously hypoechoic mass measuring 7.9*5.6 cm seen in subhepatic region in relation to the second and third part of duodenum. On computed tomography, the lesion was arising from the pancreaticoduodenal groove with marked enhancement during the arterial phase. Tortuous vessels were seen at the periphery * Harjeet Singh harjeetsingh1982@gmail.com Gautham Krishnamurthy k.gautham@gmail.com Vishal Sharma docvishalsharma@gmail.com Ajay Savlania drajaysavlania@gmail.com Rakesh Kumar Vasishta r_vasishta@yahoo.com 1 Department of General Surgery, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India 2 Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India 3 Department of Pathology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India Journal of Gastrointestinal Cancer https://doi.org/10.1007/s12029-018-00197-3