A 60-year-old woman comes to the office due to several months of lower extremity swelling. Medical history is significant for hypertension, type 2 diabetes mellitus, and hepatitis C infection. The patient was also diagnosed with latent tuberculosis 10 years ago, but she declined antibiotic therapy. Blood pressure is 120/80 mm Hg and pulse is 90/min. Physical examination shows symmetric pitting edema of the lower extremities. The liver is palpated 4 cm below the costal margin, and ascites is present. The tip of the spleen is palpated on deep inspiration. Hepatojugular reflux is present when sustained pressure is applied to the upper abdomen. The lungs are clear on auscultation. Which of the following findings is most suggestive of a cardiac cause for this patient's edema?

Question

A 60-year-old woman comes to the office due to several months of lower extremity swelling.  Medical history is significant for hypertension, type 2 diabetes mellitus, and hepatitis C infection.  The patient was also diagnosed with latent tuberculosis 10 years ago, but she declined antibiotic therapy.  Blood pressure is 120/80 mm Hg and pulse is 90/min.  Physical examination shows symmetric pitting edema of the lower extremities.  The liver is palpated 4 cm below the costal margin, and ascites is present.  The tip of the spleen is palpated on deep inspiration.  Hepatojugular reflux is present when sustained pressure is applied to the upper abdomen.  The lungs are clear on auscultation.  Which of the following findings is most suggestive of a cardiac cause for this patient's edema?

Quizplus · Accepted Answer

Hepatojugular reflux (or abdominojugular reflux) is elicited by applying firm, sustained pressure to the upper abdomen for 10-15 seconds. A positive response is defined as a sustained elevation in jugular venous pressure (JVP) >3 cm and is highly specific for elevated right-sided cardiac pressures and right ventricular (RV) failure. With RV failure, elevated hydrostatic pressure backs up through the inferior vena cava (IVC), hepatic veins, portal sinusoids, portal vein, and splanchnic circulation (eg, splenic vein, inferior mesenteric vein), creating a continuous column of elevated hydrostatic pressure. Compression of the upper abdomen forces this continuous column of blood back toward the heart; because the failing right ventricle cannot handle the increased venous return, the blood backs up into the jugular veins and causes a perceptible rise in JVP. This patient with a positive hepatojugular reflux may have constrictive pericarditis (a common cause of right-sided heart failure) due to reactivation of her latent tuberculosis. Ascites, splenomegaly, and lower extremity edema are commonly seen with RV failure, but they are nonspecific findings because they are also seen with liver cirrhosis (eg, from hepatitis C) (Choices A, E, and F). Hepatojugular reflux is not present with liver cirrhosis because the pressure backup starts at the liver and there is no continuous column of elevated hydrostatic pressure within the IVC. (Choice B) Clear lungs are expected with both liver cirrhosis and isolated RV failure and are not useful in differentiating these disease processes. Clear lungs are helpful in differentiating isolated RV failure from left ventricular (LV) failure, as pulmonary edema is expected with LV failure. A positive hepatojugular reflex is commonly present with LV failure once hydrostatic pressure backs up through the lungs to cause RV failure. (Choice D) Hepatomegaly is expected with RV failure and is not expected with liver cirrhosis (cirrhosis typically causes a shrunken liver). However, hepatomegaly is less specific for RV failure than hepatojugular reflux because hepatomegaly can also occur with an obstruction to hepatic vein or IVC blood flow (eg, hepatic vein thrombosis [Budd-Chiari syndrome]). Educational objective: Hepatojugular reflux is useful for differentiating between cardiac disease- and liver disease-related causes of ascites, splenomegaly, and lower extremity edema. Positive hepatojugular reflux (ie, sustained >3-cm rise in jugular venous pressure elicited by compression of the upper abdomen) is highly specific for right ventricular failure. Hepatojugular reflux is not expected with liver cirrhosis. References: The abdominojugular reflux sign. (http://www.ncbi.nlm.nih.gov/pubmed/10936479) Hepatojugular reflux. (http://www.ncbi.nlm.nih.gov/pubmed/30252353)

A 60-Year-Old Woman Comes to the Office Due to Several