What is considered a positive hepatic jugular reflux (HJR) or abdominal jugular reflux (AJR)?
Initially described by William Pasteur in 1885 and thought to be specific for tricuspid regurgitation (TR). This test involves distension – with or without pulsation – of the superficial veins of the neck, occurring when firm pressure (35 mmHg) is exerted over the liver or mid-abdomen which is non-tender (to avoid Valsalva maneuver). Pressure is in the direction of the spinal column, should last for one minute, and is independent of the movement of respiration.
The test is said to be positive when there is a venous rise of more than 4 cm after the patient has two spontaneous breaths.
Initial compression of the abdomen in a patient who does not guard or perform the Valsalva maneuver, usually produces an initial rise because of forced increase in venous return. But at the end of two spontaneous breaths, the initial Valsalva maneuver effect will no longer be present and the abdominal compression acts as a tourniquet and impedes venous return to the right heart.
Pathophysiology
In congestive heart failure, there is increased sympathetic outflow. Systemic venous hypertension causes the venous system, the right atrium and right ventricle to be inelastic, tight and non-compliant, i.e. increase in tone-volume. On compression of the abdomen, a unit of pressure exerted in the smaller system is transmitted to the larger system.
Differential diagnosis:
- Heart failure, including right heart “backward” failure
- Constrictive pericarditis
- Pericardial tamponade
- Tricuspid insufficiency
- IVC obstruction
False positive non-cardiac causes of positive HJR:
- Small vital capacity, inability to tolerate the upward movement of the diaphragm
- Increased blood volume
- Increased sympathetic stimulation e.g. nervousness, pain, or acute infarct
- Abdominal compression exaggerates the amplitude of the jugular pulsations without actually raising the upper levels. May give a false impression of a rise in venous pressure.
- Obstruction of the SVC below the junction of the azygous with the SVC also elevates venous pressure. Abdominal compression prevents the jugular blood from emptying freely into the azygous, thus further elevating the jugular pressure.
Sapira 1ed. p. 361-363
Constant J. Bedside Cardiology. 4th ed. 1993 p. 75-76 Fig. p. 76
