Most patients with hepatic artery aneurysms are asymptomatic and the aneurysm is discovered as an incidental finding on imaging being performed to work up unrelated symptoms or conditions. Patients with a hepatic artery aneurysm may present with abdominal pain, particularly epigastric discomfort, right upper quadrant pain, obstructive jaundice, and/or hemobilia [1] [2] [3]. In rare instances, a patient with a giant aneurysm may present with a pulsatile mass in the right upper abdomen. Patients often become clinically symptomatic when there is erosion into the biliary tree or the portal vein resulting in the development of portal hypertension or rupture of an aneurysm into the peritoneal or retroperitoneal cavity. Approximately one-third of patients present with hemobilia, characterized by jaundice, gastrointestinal bleeding, and biliary colic (Quincke's triad) [4]. Discovery of a hepatic artery aneurysm in an asymptomatic individual occurs as an incidental finding on a computed tomography or ultrasound exam being performed for an unrelated purpose [2] [3].

• Upper Abdominal Pain

  Brown pus was drained from the abscess but 13 days after the drainage process the patient complained of right upper abdominal pain and the drained fluid became blood-colored and stool became tarry in color. [ncbi.nlm.nih.gov]

  A 71-year-old woman visited the emergency room because of her suddenly developed right upper abdominal pain and jaundice for 1 day. She had taken antibiotics for infective endocarditis prior to admission. [synapse.koreamed.org]

  Case Report The patient was a 32-year-old male with the primary complaint of upper abdominal pain. [karger.com]

  Harris RD, Anderson JE, Coel MN (1975) Aneurysms of the small pancreatic arteries: A cause of upper abdominal pain and intestinal bleeding. Radiology 115:17 Google Scholar 18. [link.springer.com]

  A 39-year-old man was admitted to the hospital with upper abdominal pain. The patient had a history of partial small bowel resection, for intestinal infarction, about 5 years prior to this presentation. [kjim.org]

• Abdominal Bruit

  On examination abdominal bruit or a pulsatile mass may be found. The aneurysm may rupture into the peritoneal cavity, duodenum, portal vein and stomach or rarely into the gall bladder [2], [3]. [jpgmonline.com]

  Otherwise they may present with especially abdominal pain, nausea, vomiting and as a pulsatile mass or abdominal bruit. Some Aneurysm are not discovered until they complicate with rupture. [atmph.org]

• Chronic Abdominal Pain

  We describe a case of a successful endovascular exclusion of a hepatic artery aneurysm in a patient that suffered from chronic abdominal pain. A 68-year old man presented with chronic abdominal pain that had existed for 10 months. [ncbi.nlm.nih.gov]

  Endovascular treatment of a hepatic artery aneurysm causing chronic abdominal pain; a case report. Ann Hepatol. 2010; 9 (1): 104-6[ PubMed ] 6. Abbas MA, Fowl RJ, Stone WM, Panneton JM, Oldenburg WA, Bower TC, et al. [iranjradiol.com]

• Black Stools

  This ‘hemodynamic changes’ hypothesis would be able to explain the episode of black stool and the episodes of fresh blood in the colon. [signavitae.com]

• Decreased Bowel Sounds

  Abdominal examination revealed decreased bowel sounds without any palpable mass. However, there was a direct and indirect tenderness over the right upper quadrant and epigastrium with a positive Murphy's sign. [synapse.koreamed.org]

• Murphy's Sign

  However, there was a direct and indirect tenderness over the right upper quadrant and epigastrium with a positive Murphy's sign. [synapse.koreamed.org]

  He did not have any rebound tenderness and Murphy's sign was negative. Laboratory studies showed WBC 5700/mm 3, Hb 12.3 g/dL, hematocrit 35.0%, and platelets 183,000/mm 3. [kjim.org]

• Vascular Disease

  The great improvement in the diagnosis of vascular diseases and the increasing incidence of atherosclerosis have resulted in a wider recognition of these pathologies. [ncbi.nlm.nih.gov]

  diseases I73.0 Raynaud's syndrome I73.00 …… without gangrene I73.1 Thromboangiitis obliterans [Buerger's disease] I73.8 Other specified peripheral vascular diseases I73.89 Other specified peripheral vascular diseases I73.9 Peripheral vascular disease [icd10data.com]

  diseases [ 2 ]. [em-consulte.com]

  No history of diabetes or peripheral vascular disease was found. The USG of abdomen revealed hypoechoic mass of size 15 15 mm at the expected location of celiac trunk. [atmph.org]

• Joint Swelling

  He has not had fevers, weight loss, arthralgias, myalgias, hernia, joint swelling, laxity or dislocation, easy bruisability, visual changes, or lens dislocations, and has no family history of aneurysmal disease dissection, connective tissue disorders, [thoracickey.com]

• Arthralgia

  He has not had fevers, weight loss, arthralgias, myalgias, hernia, joint swelling, laxity or dislocation, easy bruisability, visual changes, or lens dislocations, and has no family history of aneurysmal disease dissection, connective tissue disorders, [thoracickey.com]

Most diagnostic algorithms for patients presenting with symptoms associated with hepatic artery aneurysm (e.g. mid-epigastric discomfort, abdominal pain) include imaging. The most common imaging modalities used to evaluate hepatic artery aneurysm (and generalized abdominal pain) are ultrasound scan (US), computed tomography (CT) scan with contrast, and angiogram.

On the US, a hepatic artery aneurysm may appear as a mixed echogenic mass with cystic and solid components. Calcifications are usually present in the wall of an aneurysm [5] [6]. Color doppler will demonstrate turbulent or arterial pulsatile flow that is suggestive of the lesion being vascular in origin. US can be used to rule out other vascular conditions such as arteriovenous malformations or fistulas [7] [8] [9].

Hepatic artery aneurysm can be diagnosed by a contrast-enhanced CT scan or three-dimensional CT scan. In general, a CT scan will demonstrate the characteristics of an aneurysm, adjacent anatomical structures, and any signs of rupture. Calcifications will usually be present in the vessel's wall. Thrombotic deposits in the vessel's lumen appear as ring-shaped or semilunar areas of hypodensity. Intravenous contrast allows a more definitive view of the vessel lumen.

A CT angiogram is able to further delineate small aneurysms and provide anatomical details including identification of the artery of origin. Use of CT angiogram often provides a definitive diagnosis, without the need of angiography, however, intravenous contrast is contraindicated in some patients with renal dysfunction [10] [11].

Three-dimensional contrast-enhanced magnetic resonance imaging (MRI) angiography may also be used for the diagnosis of hepatic artery aneurysm in lieu of angiography. Three-dimensional MRI is a quick, sensitive, accurate test and it provides better delineation of the arterial anatomy [12] [13].

Angiography is considered the gold standard diagnostic test for hepatic artery aneurysm. It is highly efficacious with a sensitivity of 100% [13]. Angiography, while invasive, permits diagnosis, identification of additional aneurysms, feeding vessels, and provides information necessary for treatment of an aneurysm [14].

• Normocytic Anemia

  Laboratory data on admission revealed severe normocytic anemia (red blood cell count 1,71 x 10 12 /L, hemoglobin 49 g/L, hematocrit 0,159%, mean corpuscular volume 92,7 fL), as well as elevated gamma- glutamyltransferase (599 U/L) and creatine kinase [signavitae.com]

• Entamoeba Histolytica

  Surgical treatment resolved peritonitis but Entamoeba histolytica was detected in the colonic mucosa. [ncbi.nlm.nih.gov]

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6. Parmar H, Shah J, Shah B, et al. Imaging findings in a giant hepatic artery aneurysm. J Postgrad Med. 2000; 46:104-5.
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13. Liu Q, Lu JP, Wang F, Wang L, Tian JM. 3D Contrast-enhanced MR angiography of aortic dissection: a pictorial essay. Radiographics. 2007;27:1311-21.
14. Warshauer DM, Keefe B, Maura MA. Intrahepatic hepatic artery aneurysm: computed tomography and color-flow Doppler ultrasound findings. Gastrointest Radiol. 1991;16:175-7.