Hepato Jugular Reflux

When compression is applied to the abdomen during normal respirations, the jugular venous pressure will be seen to increase transiently in normal subjects. Usually within a few cardiac cycles the pressure falls back to the precompression level. When the same maneuver is performed in a patient with heart failure, the venous pressure will increase and stay increased until the pressure is released. This is termed a positive hepato-jugular reflux (12,32,55).

This test should be performed with care to avoid discomfort or pain to the patient. If pain is produced, then it may cause the test to become falsely positive. In addition, the patient should not hold the breath or perform a Valsalva maneuver during the compression. Finally, the compression should be applied for at least 30 s.

The rise in venous pressure has been attributed to a rise in the intra-abdominal pressure causing a rise in intrathoracic pressure. Subsequently, others have attributed this effect to high sympathetic tone. A positive hepato-jugular reflux is known to occur in conditions with high sympathetic tone even in the absence of heart failure (e.g., thyrotoxicosis, anemia, hypoxemia).

With compression of the abdomen, the intra-abdominal pressure rises. The diaphragm is therefore forced towards the thorax. In patients with normal vital capacity and normal lung reserve this does not significantly change the respiratory pattern. The rise in the intraabdominal pressure increases the venous return from the viscera in the abdomen to the thorax. In normal subjects this increased volume is easily accommodated without any sustained rise in pressure in the venous capacitance system, including the superior vena cava and the jugulars. The initial rise is usually because of a transient rise in sympathetic tone caused by some apprehension on the part of the patient when compression is applied. In states with sustained elevation in sympathetic tone, the capacitance of the thoracic great veins is reduced due to veno-constriction. This will result in sustained rise in venous pressure. In patients with heart failure, the sympathetic tone is increased, therefore always resulting in a positive test (55). If pain is caused during compression, this may raise the sympathetic tone and result in a false positive test.

In patients with chronic obstructive lung disease, a false positive test may be seen because of high intra thoracic pressure created by the change in the patient's breathing pattern, which opposes the upward movement of the diaphragm. This is also a sign of decreased lung reserve.

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