Pulsatile congestive hepatomegaly

Specialty: Cardiovascular.

• pulsatile congestive liver
• systolic liver pulse

Why it occurs

• Severe tricuspid regurgitation (organic or functional)
• Advanced right ventricular failure with deep systemic venous congestion
• Constrictive pericarditis with impairment of hepatic venous return
• Restrictive cardiomyopathy with massive increase in pressure in the right atrium
• Severe tricuspid stenosis

Initial workup

Transthoracic echocardiogram with color Doppler to quantify the degree of tricuspid regurgitation, measure the diameter of the inferior vena cava and its inspiratory collapsibility, evaluate the filling pressures of the right chambers and measure the TAPSE; Abdominal ultrasound with portal Doppler and suprahepatic veins to document portal vein dilation and reversal of systolic flow in the hepatic veins; Complete blood work that includes clotting times (PT/INR), transaminases (AST, ALT), total and fractionated bilirubins, and serum albumin.

Standard management

• Furosemide — loop diuretic to deplete systemic venous volume and reduce hepatic and splanchnic congestion; 40 to 80 mg intravenously or orally in divided doses
• Spironolactone — aldosterone receptor antagonist, indicated as first choice for the control of ascites and hepatic congestion by opposing secondary hyperaldosteronism due to renal hypoperfusion; 50 to 100 mg once daily orally, adjusting according to serum potassium
• Torasemide — alternative loop diuretic with better gastrointestinal absorption in the presence of intestinal wall edema; 10 to 20 mg once daily orally
• Sildenafil (phosphodiesterase-5 inhibitor indicated only in cases of precapillary pulmonary arterial hypertension that causes functional tricuspid insufficiency and right ventricular failure; 20 mg three times a day orally, under strict pressure control).