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Hepatojugular Reflux – Sign of Heart Failure

The hepatojugular reflux is a clinical sign indicating heart failure or elevated venous pressure. Pressure applied to the liver causes a visible rise in the jugular veins of the neck.

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Things worth knowing about "Hepatojugular"

The hepatojugular reflux is a clinical sign indicating heart failure or elevated venous pressure. Pressure applied to the liver causes a visible rise in the jugular veins of the neck.

What is Hepatojugular Reflux?

The hepatojugular reflux (also known as the hepatojugular sign or abdominojugular test) is a clinical finding assessed during physical examination. It describes the rise in jugular venous pressure in response to manual compression of the right upper abdomen over the liver. This phenomenon occurs when the right side of the heart is unable to accommodate and forward the additional blood volume displaced into the venous circulation by the applied pressure.

Causes and Clinical Significance

A positive hepatojugular reflux is an important indicator of right-sided or biventricular heart failure. It suggests impaired venous return to the heart and elevated right atrial pressure. Underlying conditions may include:

Right heart failure: The right ventricle is unable to pump blood forward adequately.
Constrictive pericarditis: Thickening or scarring of the pericardium restricts cardiac filling.
Restrictive cardiomyopathy: Stiffening of the heart muscle impairs ventricular filling.
Pulmonary hypertension: Elevated pressure in the pulmonary circulation increases strain on the right heart.
Tricuspid valve disease: Disorders of the right-sided heart valve can lead to venous backflow.

How is the Test Performed?

The patient is positioned at an angle of approximately 30 to 45 degrees. The examiner applies steady pressure to the right upper abdomen for about 10 to 15 seconds while observing the jugular veins in the neck for changes in filling.

Interpretation of Results

Positive finding: The jugular veins rise significantly during compression (more than 3 cm) and remain elevated after the pressure is released. This is consistent with heart failure or elevated central venous pressure.
Negative finding: The jugular veins show no rise, or only a brief and rapidly resolving increase. This is considered a normal response.

Diagnostic Role

The hepatojugular reflux test is used as part of the clinical cardiac examination and complements other signs of heart failure such as peripheral oedema, dyspnoea, or an enlarged liver (hepatomegaly). It is not a standalone diagnostic tool but provides valuable guidance for further investigation through echocardiography, ECG, or laboratory tests (e.g., BNP levels).

Distinction from Other Findings

It is important to differentiate the hepatojugular reflux from other causes of elevated jugular venous pressure, such as superior vena cava obstruction due to a mediastinal mass, or increased intra-abdominal pressure without a cardiac cause. A careful clinical assessment by a qualified healthcare professional is therefore always required.

References

Kasper D. L. et al. - Harrison's Principles of Internal Medicine, 21st edition, McGraw-Hill (2022)
Maisel A. S., Atwood J. E., Goldberger A. L. - Hepatojugular reflux: useful in the bedside diagnosis of tricuspid regurgitation. Annals of Internal Medicine, 101(6):781-782 (1984). PubMed PMID: 6497192
Ponikowski P. et al. - 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal, 37(27):2129-2200 (2016)

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