The Hepato-Jugular Reflux (HJR) test was originally described by Pasteur in 1885 as a sign of tricuspid regurgitation (TR) . Rondot later coined the term HJR (or rather, Le reflux hépato-jugulaire) and noted conditions other than TR could lead to the response . In 1925 Lian and Blondel described that pressure anywhere on the abdomen can elicit jugular venous filling [3, 4], and abdominojugular replaced hepatojugular. Though abdominal pressure is thought to increase venous return, the mechanism of the AJT remains unclear – hence the term ‘reflux’ is controversial.
While JVD relates to right sided pressures (elevated CVP), the AJT predicts an elevation in PCWP (pulmonary capillary wedge pressure) > 15 mmHg [4, 5, 6, 7], though causes of decreased right ventricular outflow need to be considered as well (right sided MI, restrictive CM, constrictive pericarditis, tricuspid stenosis, and others) .
When Stephen McGee pooled performance of the AJT it had a +LR of 8 for PCWP >15 mmHg with a -LR of 0.3 . The JV does not need to be elevated for the AJT to have clinical significance though there is some evidence that combining JVD + AJT may discriminate elevation PCWP the best (+LR 4, -LR 0.3 in the study both combined were evaluated ).
Performing the test
It requires you to find the JVP/JVD (which has only somewhat useful operating characteristics).
- Find the JV meniscus
- Palpate anywhere on the mid-abdomen (the RUQ is not necessary and may be more painful)
- Use firm, even pressure (between 20-35 mmHg) for ≥ 10 sec (15-30 sec reported in some texts)
- Avoid a Valsalva response / Avoid pain – have the patient breath calmly with his/her mouth open
- Positive if sustained increase ≥ 4 cm (≥ 3 cm in some references)
- W. Pasteur: Note on a new physical sign of tricuspid regurgitation. Lancet. 2:524, 1885.
- E. Rondot. Le reflux hépato-jugulaire. Gazette hebdomadaire des sciences me’dicales de Bordeaux. 19, 567-571, 1898.
- C. Lian, A. Blondel. Presse medicale 33, 481, 1925.
- MB Matthews, J Hampson. Hepatojugular reflux. Lancet. 26;1(7026):873-6, 1958.
- GA Ewy. The abdominojugular test: technique and hemodynamic correlates. Ann Intern Med. 15;109(6):456-60, 1988.
- SM Butman, et al. Bedside cardiovascular examination in patients with severe chronic heart failure: importance of rest or inducible jugular venous distension. J Am Coll Cardiol. 22(4):968-74,1993.
- PR Marantz, et al. Clinical diagnosis of congestive heart failure in patients with acute dyspnea. Chest 97(4):776-81, 1990.
- J Wiese. The abdominojugular reflux sign. Am J Med. 109(1):59-61, 2000.
- Stephen McGee’s Evidenced Based Physical Diagnosis, 4th ed, Elsevier, Philadelphia, PA, 2018.