The patient should undergo hemodynamic cardiac catheterization. He has evidence of liver disease most likely caused by constrictive pericarditis. Patients with constrictive pericarditis can develop severe symptoms of right-sided congestion that can lead to chronic hepatic congestion and hepatopathy. When detected early, cirrhosis can be reversible if constrictive pericarditis is identified and treated in a timely manner with surgical pericardiectomy. An important clue that suggests constrictive pericarditis as a contributor to hepatopathy is an elevated jugular venous pulse, which demonstrates the presence of elevated right atrial pressures. The central venous pressure is rarely abnormal in patients with primary liver disease. A hemodynamic study with an echocardiogram is sufficient to diagnose constrictive pericarditis in most patients. For patients such as this one with an indeterminate echocardiogram, the most appropriate next step is an invasive hemodynamic study with cardiac catheterization, which provides the greatest sensitivity and specificity for the diagnosis of constrictive pericarditis.

A liver biopsy may be helpful in patients with liver disease of unknown etiology or to gauge the type and degree of liver injury or fibrosis. A liver biopsy is not performed prior to the completion of less invasive tests, such as a liver chemistry profile and ultrasonography. In this patient, the elevated central venous pressure suggests cardiac rather than primary liver disease, and cardiac catheterization with hemodynamic measurements is more likely to prove diagnostic.

B-type natriuretic peptide level is often normal or minimally elevated in patients with constrictive pericarditis despite the elevated central venous pressure. However, measurement of B-type natriuretic peptide will not establish the diagnosis of constrictive pericarditis or guide therapy.

Judicious use of loop diuretics is important in patients with constrictive pericarditis to reduce dyspnea and edema, but because higher filling pressures are needed to maintain stroke volume, overly aggressive diuresis can reduce cardiac output, causing dizziness and orthostatic hypotension.