What are the signs and symptoms of a splenic artery aneurysm?

Signs and Symptoms of Splenic Artery Aneurysm

Most splenic artery aneurysms are asymptomatic at discovery and found incidentally during abdominal imaging, but approximately 20% present with either chronic upper abdominal pain or life-threatening acute rupture. 1

Asymptomatic Presentation (Most Common)

• The majority of splenic artery aneurysms produce no symptoms and are discovered incidentally during laparotomy, angiography, or cross-sectional imaging studies 1, 2
• Increasing numbers are being detected during routine ultrasound evaluations, particularly in pregnant women 1
• Calcified aneurysms may appear as an incidental ring-like calcification on plain abdominal X-rays in the left upper quadrant 3

Symptomatic Presentation (20% of Cases)

Chronic Symptoms

• Left upper quadrant or epigastric abdominal pain is the most common chronic symptom 1, 3
• Pain may radiate to the left flank or back 4
• Symptoms may be vague and of unknown etiology, particularly in multiparous women 3

Acute Rupture Presentation

The classic presentation of rupture includes abdominal pain with syncope and hemodynamic instability. 4

"Double Rupture Phenomenon" (25% of Rupture Cases)

• Initial herald bleed produces warning symptoms with self-contained bleeding into the lesser sac 4
• This is followed by a major secondary rupture with rapid intra-abdominal bleeding and hemorrhagic shock 4
• This two-stage pattern provides a critical window for intervention before catastrophic bleeding occurs 4

Intraperitoneal Rupture

• Massive bleeding into the free peritoneal cavity 5, 6
• Severe hemodynamic instability and shock 7, 5
• Abdominal distension and peritoneal signs 4
• Mortality rates of 10-25% in non-pregnant patients 1

Gastrointestinal Bleeding (Rare but Critical)

• Massive upper gastrointestinal bleeding from erosion into the stomach is a rare but life-threatening presentation 7, 2, 5
• May present with hematemesis and melena 5, 6
• Can have a relapsing course with episodes of bleeding separated by symptom-free intervals 7
• Endoscopy may show gastric bulging in the greater curvature or posterior wall with erosion and visible vessel 5
• Lower gastrointestinal bleeding from erosion into the colon has also been reported 6

High-Risk Populations Requiring Heightened Suspicion

Pregnancy (Highest Risk)

• Greatest risk occurs in the third trimester when hyperdynamic circulation maximizes splenic blood flow 4
• Presents with abdominal pain and syncope 4
• Maternal mortality reaches 70-95% and fetal mortality exceeds 90% in advanced rupture cases 4, 1
• Critically, up to 50% of pregnancy-related ruptures occur with aneurysms <2 cm, making size unreliable for risk stratification 1

Cirrhosis and Portal Hypertension

• Patients with cirrhosis and severe splenomegaly warrant attention for splenic artery aneurysm presence 4
• Portal hypertension increases both formation and rupture risk 1

Multiparous Women

• Female gender and multiparity are established risk factors 1, 2, 3

Clinical Pitfalls to Avoid

• Negative endoscopy does not exclude splenic artery aneurysm as a bleeding source, especially if performed between active bleeding episodes 7
• Ultrasound may be falsely negative in acute settings 7
• In patients with unexplained left upper quadrant pain, particularly multiparous women, splenic artery aneurysm must be considered even with normal initial imaging 3
• Immediate CT angiography is essential when splenic artery aneurysm is suspected as a bleeding source, as it establishes diagnosis and guides therapy 7