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it is reported to have an incidence rate of 0.7% in the normal population , even though rates as high as 10% have been found on necropsy studies .
if intact , saas are typically asymptomatic but may be associated with manifestations such as epigastric pain or obstructive jaundice .
fatal hemorrhage , however , commonly occurs subsequent to aneurysm rupture  the only significant reported complication of saa .
reports of rupture rates are inconsistent and vary from 5%-10% to as high as 46% , with the highest incidence reported in young pregnant females . , mortality rates range from 10%-25% in non - pregnant patients and may reach 56% in pregnant females . 
 

the incidental diagnosis of saa is becoming increasingly more frequent with the increase in use of cross - sectional imaging modalities ( e.g. , computed tomography and magnetic resonance imaging ) for the investigation of abdominal pain . 
 

the cause of saa is not clearly identified , yet the increased volume of blood flowing through the splenic artery can contribute to its formation .
it has also been associated with hypertension , portal hypertension , cirrhosis and liver transplantation . 
 

the following is a case presentation of a patient with saa as a rare cause of abdominal pain and ascites .
the diagnostic approach , including appropriate imaging tests , and the management steps taken are discussed below along with a review of the literature . 


 a 29-year - old male was admitted to ghaem hospital , mashad , iran in june 2013 with complaints of a transient episode of severe epigastric pain and syncope which had occurred the previous day . on admission
, he had intermittent abdominal pain in the epigastric and periumbilical regions without any other associated symptoms .
, he had a blood pressure of 100/70 mmhg and a pulse rate of 100 beats per minute , with normal body temperature recordings and blood oxygen saturation levels .
on the abdominal examination , a symmetric distention was noted with mild tenderness in the epigastrium without any evidence of peritoneal irritation ( e.g. , abdominal guarding or rebound tenderness ) or a pulsatile mass .
the complete blood count revealed a white blood cell ( wbc ) count of 16700/mm and a left shift without any abnormal hemoglobin levels or platelet counts .
the lactate dehydrogenase levels had increased to approximately six times that of the upper limit of normal .
emergency abdominal ultrasound ( u / s ) showed mild ascites with bloody paracentesis indicative of a high serum - ascites albumin gradient ( 2.2 g / dl ) and high ascites protein ( 2.7 g / dl ) .
in addition , the ascites analysis demonstrated 5630 
 wbcs / mm , with a predominance of polymorphonuclear cells , numerous red blood cells , and negative bacterial smears and cultures . 
 

based on the symptom of abdominal pain and a high - gradient - high - protein abdominal fluid analysis doppler ultrasonography of the inferior vena cava ( ivc ) and the hepatic and portal veins were performed to evaluate for intra - abdominal vein thromboses , which included budd - chiari syndrome . with normal
doppler results the patient was scheduled to undergo magnetic resonance venography ( mrv ) for better assessment of the ivc .
however , prior to further imaging , a repeat episode of acute severe generalized abdominal pain and hypotension occurred , which lasted approximately three minutes .
subsequent emergency abdomino - pelvic computed tomography scan showed thick collections in the pelvic area with a similar high albumin - gradient and protein results on repeat paracentesis . 
 

a ruptured abdominal vascular aneurysm was suspected with a repeat bloody paracentesis and the impression was strengthened by the falling hemoglobin levels , which declined from the initial normal value to levels as low as 8.7 g / dl .
therefore , after hemodynamic stabilization , the patient underwent an urgent abdominal computed tomographic angiography ( cta ) and mrv , both of which detected a 3 cm splenic aneurysm in the distal part of the splenic artery near the pancreas with small amounts of fluid that surrounded the defect 
 ( figures 1 , 2 ) . 
 

iv contrast - enhanced axial and coronal multiplanar reformation ct images of a 29-year -old man with abdominal pain showing a 3 cm aneurysm located near the splenic hilum , with adjacent retroperitoneal hemorrhage . 
 
 a three - dimensional mr angiographic arterial - phase image with maximum intensity projection performed in the coronal oblique view after enhancement with gadolinium in a29-year - old man with abdominal pain revealing an aneurysm in the splenic artery . 
 

at two hours prior to the planned exploratory laparotomy the patient s condition suddenly deteriorated with progressive abdominal distention , hypotension and confusion . despite aggressive resuscitation with intravenous crystalloid fluids ,
he was immediately taken to the operating room , where an exploratory laparotomy revealed approximately three liters of blood in the peritoneal cavity and blood filling the lesser sac .
the pancreas appeared slightly edematous in the region of the aneurysm . with a rupture detected in the saa and adhesions surrounding the area
, we performed a ligation of the proximal portion of the artery together with resection of the aneurysm and spleen .
later , histologic examination of the vessel wall showed a perforated arteriosclerotic aneurysm of the splenic artery with normal spleen pathology .
there were no complications after the surgical operation and the patient was discharged from the hospital in good condition ten days later . 


 saa are the second most common intra - abdominal aneurysms after those of the aortoiliac arteries . with a mean size of 2.1 cm , saas are rarely larger than 3 cm .
therefore , giant aneurysms are extremely rare and previous reports of aneurysms 8 cm have not exceeded ten cases .
the exact etiology of saa is not known , but risk factors for the disease include arterial fibro dysplasia , multiparity , arteriosclerosis , pancreatitis , trauma , chronic liver disease and portal hypertension , with the latter two considered the most common etiologies . 
 

saa is a rare , typically asymptomatic clinical entity with only 27% of inflicted patients presenting with abdominal pain .
nevertheless , the condition is increasingly being recognized due to the availability of advanced imaging techniques .
the risk for rupture , however , reaches 50% in pregnant patients in whom 65% of all saas occur .
therefore , since saas have been largely described in females the occurrence of such a condition in a young healthy male with no associated medical history , especially that of trauma or portal hypertension , is rare with only a handful of case reports reporting similar presentations . 
 

an acute - onset pain in the left upper quadrant is usually indicative of rupture which may be associated with hypotension or only significantly delayed signs of hemorrhage .
such a  double rupture  phenomenon ( e.g. , acute pain followed by delayed signs of hemorrhage ) is reflective of an initial bleeding episode confined to the lesser sac which , approximately 6 - 96 hours later , is followed by free intraperitoneal hemorrhage and shock , eventuating in the collapse of the patient .
this two - phase phenomenon , which has been reported in 25% of cases , provides an invaluable opportunity for the attending clinician to make a proper diagnosis and timely intervention . in the present case ,
a similar pattern of presentation , with two episodes of sudden abdominal pain and mild hypotension provided sufficient time for diagnostic workup prior to emergency laparotomy . however , an unnecessary delay in the decision to perform surgery put the patient at a higher risk of mortality due to serious intraperitoneal hemorrhage .
available evidence has suggested that painful or symptomatic aneurysms , an aneurysm of any diameter in a pregnant female , following liver transplantation , and an aneurysm more than 2 cm should be operated as soon as possible .
therefore , it is highly recommended that in such cases , as soon as a diagnosis of saa with leakage is made , immediate surgical operation be performed prior to the completion of the 
there are basically two approaches to the treatment of saas  endovascular or surgical . for elective cases of unruptured true aneurysms
however , laparoscopic surgery is indicated for more complicated cases and aggressive surgical operations for ruptured saas .
, preservation of the spleen is desirable yet difficult in the case of rupture . 
 
 finally ,
although fortunately rare , saas are associated with high mortality rates and thus a high clinical suspicion is vital in avoiding a misdiagnosis .
the diagnosis of saa should be contemplated in any patient with sudden - onset pain in the upper abdomen with or without hypotension , especially when falling hemoglobin levels and new - onset ascites complicate the clinical picture .
timely detection of a ruptured saa and emergent surgical management significantly improves the patient s chances of survival , particularly in the presence of the 

 we would like to thank the vascular surgery department at emamreza hospital and the medical team at ghaem hospital .
splenic artery aneurysm ( saa ) is a rare and potentially life - threatening clinical entity that carries a risk of rupture and peritoneal hemorrhage . 
 when ruptured , it typically manifests as abdominal pain with hemodynamic instability . 
 this is a report about a 29-year - old male admitted for evaluation of recentonset ascites following the spontaneous resolution of a transient episode of severe epigastric and left upper quadrant pain with syncope the preceding day . 
 paracentesis revealed bloody fluid . 
 abdominal computed tomographic angiography ( cta ) and magnetic resonance venography ( mrv ) showed a three centimeter saa . during admission , 
 prompt exploratory laparotomy was performed that revealed excessive intraperitoneal hemorrhage due to a ruptured saa . 
 the pathology report confirmed that the saa had developed secondary to atherosclerosis . 
 careful history taking together with appropriate imaging tests and emergent surgical intervention led to a timely diagnosis and the patient s survival .