How do you elicit the hepatojugular (liver and jugular vein) reflex?

How to Elicit the Hepatojugular Reflex

The hepatojugular reflex is elicited by applying firm, sustained pressure over the right upper quadrant of the abdomen for 15 seconds while observing the internal jugular vein for a sustained rise in venous pressure of ≥1 cm (or ≥4 cm H2O). 1

Patient Positioning and Preparation

• Position the patient supine with the head of the bed elevated at 30-45 degrees to optimize visualization of the internal jugular vein 1
• Ensure adequate lighting to visualize the jugular venous pulsations in the neck 2
• Have the patient breathe normally during the maneuver—breath-holding should be avoided as it artificially elevates venous pressure 1

Technique for Applying Abdominal Pressure

• Place your hand firmly over the right upper quadrant of the abdomen, centered over the liver 1, 2
• Apply sustained, firm pressure (not intermittent compression) for a full 15 seconds, as this duration is adequate for the test to stabilize in the vast majority of patients 1
• The pressure should be sufficient to compress the liver and increase venous return, but not so forceful as to cause pain or trigger a Valsalva maneuver 1

Observing and Interpreting the Response

• A positive hepatojugular reflex is defined as a sustained rise in jugular venous pressure of ≥1 cm (or ≥4 cm H2O) that persists throughout the 15-second compression period 1
• Watch the internal jugular vein throughout the entire compression—the venous column should rise and remain elevated during sustained pressure 1
• A transient rise that falls back to baseline during continued compression is considered negative 1
• The test can also be performed during right heart catheterization, measuring a sustained increase in right atrial pressure, which correlates well with bedside clinical assessment (κ = 0.74) 1

Clinical Significance and Hemodynamic Correlates

• The hepatojugular reflex correlates best with baseline mean right atrial pressure (r = 0.59) and right ventricular end-diastolic pressure (r = 0.51) 1
• A positive test has high sensitivity (1.0) and specificity (0.85) for predicting right atrial pressure >9 mm Hg 1
• It also demonstrates high sensitivity (0.90) and specificity (0.89) for right ventricular end-diastolic pressure >12 mm Hg 1
• In heart failure patients, the hepatojugular reflex correlates with pulmonary capillary wedge pressure and reflects increased central blood volume 3, 4

Prognostic Value

• A positive hepatojugular reflex on hospital discharge is an independent predictor of 6-month mortality in acute heart failure patients (hazard ratio: 1.689; 95% CI: 1.032-2.764) 3
• The test should be checked routinely throughout hospitalization and especially at discharge in patients with heart failure 3

Common Pitfalls to Avoid

• Insufficient duration of compression: The test must be sustained for the full 15 seconds, as shorter durations may miss positive responses 1
• Inadequate pressure: Too gentle compression will not adequately increase venous return 1
• Patient breath-holding or Valsalva: This artificially elevates venous pressure and creates false positives—ensure normal breathing throughout 1
• Observing only transiently: A brief rise that returns to baseline during continued compression is negative—the elevation must be sustained 1