Physical Exam: Neck Veins

Technique for Examining Hepatojugular Reflux (HJR)

Hepatojugular reflux is the distension of the neck veins precipitated by the maneuver of firm pressure over the liver. It is seen in tricuspid regurgitation, heart failure due to other non-valvular causes, and other conditions including constrictive pericarditis, cardia tamponade, and inferior vena cava obstruction. The HJR maneuver may be performed as follows:

1. The patient is positioned supine with elevation of the head at 45 degrees.
2. Look at jugular pulsations during quiet respirations (baseline JVP).
3. Apply gentle pressure (30-40 mm Hg) over the right upper quadrant or middle abdomen for at least 10 seconds (some suggest to 1 minute).
4. Repeat the JVP.
5. An increase in JVP of >3 cm is a positive HJR test.

Note: Normal subjects will have a decrease in JVP with this maneuver since venous return to the heart will be reduced. The jugular venous pressure may transiently rise and then return to normal or decrease within 10 seconds.

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