Which clinical sign is characterized by a pulsatile hepatomegaly with a systolic impulse felt below the costal margin?

Explanation

## Pulsatile Hepatomegaly: Mechanism and Significance **Key Point:** Pulsatile hepatomegaly is a specific clinical sign indicating tricuspid regurgitation (TR), where the hepatic vein transmits the systolic backflow of blood from the right ventricle directly to the liver. ### Pathophysiology In tricuspid regurgitation, systolic incompetence of the tricuspid valve allows blood to reflux into the right atrium and hepatic veins during ventricular systole. This creates a visible and palpable systolic impulse in the liver edge, felt as an expansile pulsation below the costal margin. ### Clinical Examination Technique 1. Patient supine or semi-recumbent 2. Palpate the liver edge with flat hand 3. Feel for a systolic impulse (not diastolic) 4. The pulsation is synchronous with carotid pulse 5. May be accompanied by prominent hepatic venous pulsation on inspection ### Differential Features | Sign | Mechanism | Character | Associated Findings | |------|-----------|-----------|---------------------| | **Pulsatile hepatomegaly (TR)** | Systolic backflow via hepatic veins | Systolic impulse, expansile | JVD, prominent CV wave in JVP | | **Hepatic congestion (RV failure)** | Chronic venous engorgement | Smooth enlargement, tender | Ascites, peripheral edema, RV heave | | **Fatty infiltration** | Lipid accumulation | Smooth, non-tender | No pulsatility, normal JVP | | **Acute hepatitis** | Inflammation and edema | Tender hepatomegaly | Jaundice, elevated transaminases | **High-Yield:** Pulsatile hepatomegaly is a sign of **significant tricuspid regurgitation** and indicates right heart dysfunction. It is distinct from simple hepatomegaly and carries hemodynamic significance. **Clinical Pearl:** The presence of a pulsatile liver with prominent CV waves in the jugular venous pulse strongly suggests moderate-to-severe TR and warrants echocardiography for quantification. **Mnemonic:** **PULSATILE = TR** — Pulsatile hepatomegaly = Tricuspid Regurgitation.