ONE OF THE MOST common means of detecting heart failure is to assess the patient for the presence of hepatojugular reflux. What's the connection? It has to do with venous return: In right-sided heart failure, abdominal compression increases venous return to the heart, which can markedly increase jugular vein distension and pressure.

In this article, I'll help you understand the steps you need to take to evaluate your patient for hepatojugular reflux. Keep in mind that you shouldn't perform this test if the patient exhibits any abdominal guarding.

Step by step

After explaining the procedure to the patient and washing your hands, place him supine and elevate the head of his bed to 45 degrees. With the patient in this position, you can assess him for distension of the internal and external jugular veins. Obvious bilateral distension when the head is elevated above 30 degrees indicates an abnormal increase in venous volume. Note the level of jugular venous distension for later comparison.

Next, stand at your patient's right side and ask him to turn his head to the left. Tell him to breathe normally through his open mouth; he shouldn't hold his breath during the test. Then, with your right hand, apply firm pressure on his midabdomen (at the periumbilical area) while assessing the highest point of oscillation in his right internal jugular vein.

Continue applying firm pressure to his abdomen for 30 to 60 seconds. This moves venous blood from the liver sinusoids to the venous system. If the heart can pump this additional volume, the jugular veins will rise for a few seconds, then return to the previous level. But if the patient has volume overload secondary to heart failure, jugular venous pressure rises and stays elevated for as long as you apply firm pressure. If the height of his neck veins increases by at least 3 cm throughout compression, he has positive hepatojugular reflux (see illustration).

Keep in mind, though, that this is only one piece of the puzzle: You shouldn't automatically interpret a positive hepatojugular reflux as diagnostic of fluid overload unless it correlates with the patient's vital signs, breath and heart sounds, peripheral edema, and daily weights. A patient with a positive hepatojugular reflux could also have a pulmonary embolism, pulmonary hypertension, or kidney disease, to name a few.

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