Hepatic artery pseudoaneurysm (HPA) with hemobilia is an unusual complication of hepatic trauma. Initial operative management can have an impact on the development of HPA, and definitive management is difficult. A total of 482 consecutive patients with liver injury were prospectively analyzed. Six of these (1.2%) developed HPA with hemobilia. Three patients developed HPA after penetrating injuries, and 3 after blunt trauma. All 6 patients had hemobilia with massive upper gastrointestinal hemorrhage; HPA was confirmed by angiography. A total of 80% had bile leaks as revealed by hepatobiliary scans. One patient was nonseptic and had a small intrahepatic cavity, and the patient underwent successful embolization of the HPA. The remaining 5 had unexplained sepsis with large intrahepatic cavities and underwent operation. Two died due to massive blood loss and coagulopathy during attempted cavity débridement prior to gaining vascular control. One had right hepatic artery ligation in lieu of resection and subsequent lobectomy after recurrence of hemobilia; the other 2 had formal hepatic resections. No survivors had further rebleeding. We conclude that (1) HPA with hemobilia is predisposed by bile leak; (2) embolization appears appropriate for patients with small cavities without sepsis; and (3) débridement and drainage, which may require formal resection, are necessary for those with large cavities and/or sepsis after vascular control is obtained either by preoperative embolization or intraoperatively.