Splenic artery aneurysm (SAA) is the third most common abdominal vessel aneurysm after abdominal aortic aneurysm and iliac artery aneurysm. In addition, it is the most common visceral vessel aneurysm. With the increasing availability of imaging examinations, there has been a rise in the reported cases of SAA [1, 2]. The major complication of SAA was rupture. The risk of rupture for a true aneurysm is very low (2–3%); however, this risk substantially increases for pseudoaneurysms (37–47%) with a 90% mortality rate [3]. Their rupture leads to massive life-threatening bleeding with hemodynamic instability.

Liu et al. reported that SAAs usually rupture into the peritoneal cavity, and < 30% of them perforate into the lumen of intra-abdominal visceral organs [4]. Shibuta reported that the percentage of perforation to the peritoneal cavity, pancreatic duct, stomach, colon, retroperitoneum, and pancreatic cyst was 51.0%, 21.6%, 9.8%, 9.8%, 3.9%, and 3.9%, respectively [5]. Thus, the perforation of SAAs in the stomach is rare.

In case of non-ruptured SAAs, the patient is asymptomatic. They are most commonly diagnosed during examination for other reasons. If their vital signs are stable with no signs of bleeding, the lesion must be evaluated using contrast-enhanced computed tomography and selective angiography. In such cases, the following treatments are recommended: percutaneous, intravascular embolization, and stenting or laparoscopic ligation of the aneurysm [1, 2, 6, 6,7,8]. In the case of a ruptured SAA, the patient had upper abdominal pain and presented with hematemesis or hematochezia, with hypovolemic shock.

Our patient experienced rupture with massive intragastric bleeding and syncope because of hypovolemic shock. Contrast-enhanced CT of his abdomen detected a SAA with intragastric bleeding. If the bleeding point is not identified, hemostasis during laparotomy is very challenging. However, in our case, the bleeding site was detected, and we could perform laparotomy.

In contrast, some studies have reported the success rates from 75 to 85% following interventional radiology (IVR) [11, 12]. Recently, IVR has been recognized as a first-choice of treatment for SAA. IVR is chosen because it is minimally invasive, can be performed in patients with poor general condition, such as in those with hemorrhagic shock, and can be performed in patients with serious conditions that pose a high risk of general anesthesia—similar to this case. The angiographic treatment might be associated with other severe complications, including the formation of abscesses in the spleen and embolism in the arterial system [8]. However, even if a patient suffered such complications, surgery could be performed after the condition was stabilized by IVR.

Angiography might not be a definitive treatment in patients with aneurysm and gastric bleeding who have a fistulous connection. Moreover, there have been several reports of post-procedural coil migration and coils extruding into the gastric lumen in such cases [9, 10]. However, in this regard, given that the aneurysm was located in the distal splenic artery in the present case, temporary hemostasis was likely to be achieved with coiling in the proximal splenic artery, based on the intraoperative findings.

Because of insufficient time, we could not wait for the radiologist to arrive; therefore, we opted for surgery in this case. Although IVR is the first-choice of treatment for splenic aneurysms, emergency surgery may be an option when the aneurysm is large and perforates the gastrointestinal tract and there is a risk of coil dislodgement or when the vitals are unstable and one cannot wait for the radiologist to arrive, as in this case.