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PubMed This is a summary of 15 peer-reviewed journal articles Updated
Maternal-Fetal Medicine

CDH Liver Up vs Liver Down: What Does It Mean?

At a Glance

In congenital diaphragmatic hernia (CDH), a 'liver down' diagnosis means the liver remains in the abdomen, typically indicating a better prognosis. 'Liver up' means part of the liver has moved into the chest, restricting lung growth and usually requiring more intensive medical interventions.

In this answer

3 sections

01

How Liver Position Affects Lung Growth

02

What Do the Survival Rates Tell Us?

03

What Else Does “Liver Up” Mean for Treatment?

Receiving a diagnosis of congenital diaphragmatic hernia (CDH) is overwhelming, and hearing medical terms like “liver up” can add to the fear and confusion. It is important to know first that the survival statistics discussed here apply to isolated CDH—meaning there are no other major birth defects or genetic conditions present. If your baby’s CDH is not isolated, these numbers may not directly apply to your unique situation.

If your doctor mentioned that your baby’s liver is “up,” they are referring to intrathoracic liver herniation. This means that a portion of the baby’s liver has moved up through the hole in the diaphragm and into the chest cavity [1][2]. Conversely, “liver down” means the liver remains entirely in the abdomen [3]. Because the liver is a large, solid organ, a “liver up” diagnosis means it takes up significant space in the chest, leaving less room for the lungs to grow [4]. As a result, “liver up” generally indicates a more severe case of CDH and is associated with lower overall survival odds compared to a “liver down” diagnosis [5][6]. (Note: In right-sided CDH, the liver is almost always “up” due to its natural position on the right side of the body.)

How Liver Position Affects Lung Growth

In a developing baby, the lungs need space in the chest cavity to grow and mature. When the liver moves up into the chest, it physically compresses the lungs, leading to more severe pulmonary hypoplasia (underdeveloped lungs) [7][4]. The amount of lung tissue a baby has is typically measured by the Observed to Expected Lung-to-Head Ratio (O/E LHR). Because the liver occupies so much space, babies with their liver “up” usually have a lower O/E LHR [7][1].

What Do the Survival Rates Tell Us?

The position of the liver is one of the most critical predictors of neonatal survival, used alongside the O/E LHR to help doctors understand the severity of the CDH [5][2].

  • Liver Down: When the liver stays in the abdomen, it typically indicates a smaller hole in the diaphragm and a better prognosis. Survival rates in these cases are generally high, often ranging from 70% to over 90% depending on the exact lung size [8][9].
  • Liver Up: For left-sided CDH with the liver up, the condition is more complex. Across all left-sided “liver up” cases, average survival rates have been reported around 45% [10].

However, survival is highly dependent on the O/E LHR. For example, in a “moderate” CDH case (where the O/E LHR is between 25% and 45%), a baby with a “liver down” may have an 80-90% chance of survival, whereas the same lung size with a “liver up” might see survival odds closer to 50-60% [9][8]. In severe cases (O/E LHR under 25%) with the liver up, survival rates are much lower without specialized fetal intervention, such as FETO (Fetal Endoscopic Tracheal Occlusion), a procedure where a tiny balloon is placed in the baby’s airway to help the lungs grow [11][12].

What Else Does “Liver Up” Mean for Treatment?

A “liver up” diagnosis not only impacts survival rates but also influences the kind of care your baby will need after birth:

  • ECMO Support: Babies with their liver up are at a higher risk of needing Extracorporeal Membrane Oxygenation (ECMO) [13][14]. This is a specialized machine that temporarily takes over the work of the heart and lungs, giving the baby’s lungs crucial time to rest and respond to medical management.
  • Pulmonary Hypertension: The compression of the lungs often leads to more severe and persistent high blood pressure in the lung vessels after birth [4][15].
  • Surgical Complexity: A herniated liver often indicates a larger defect in the diaphragm, which usually requires a synthetic patch for repair rather than a simple stitch closure.

Every baby is unique, and these numbers and possibilities are just a starting point for discussions with your care team.

Common questions in this guide

What does a 'liver up' CDH diagnosis mean?
A 'liver up' diagnosis means that a portion of your baby's liver has moved through the hole in the diaphragm and into their chest cavity. Because the liver is a large, solid organ, it takes up space that the lungs need to grow, which generally makes the condition more severe.
How does liver position affect my baby's CDH survival rate?
If the liver remains in the abdomen (liver down), the prognosis is typically better, with survival rates often ranging from 70% to over 90%. When the liver is up in the chest, survival rates are generally lower and depend heavily on the exact size of your baby's developing lungs.
What is the O/E LHR and why does it matter?
The Observed to Expected Lung-to-Head Ratio (O/E LHR) is a prenatal ultrasound measurement used to estimate how much lung tissue your baby has. Doctors use this measurement alongside the liver's position to accurately predict the severity of the CDH and plan for delivery and treatment.
Will a 'liver up' diagnosis change how my baby is treated?
Yes, a liver up diagnosis often means your baby will need more intensive support after birth, such as ECMO heart and lung bypass. It also increases the likelihood that surgeons will need to use a synthetic patch, rather than simple stitches, to repair the diaphragm.
Should we consider fetal interventions like FETO for CDH?
FETO is a specialized procedure performed before birth that may help lungs grow in severe cases of CDH, often when the liver is up and lung measurements are very low. You should discuss with your maternal-fetal medicine specialist to see if you qualify for this intervention.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.What is my baby's current O/E LHR, and how does that combined with the liver position affect their prognosis?
  2. 2.Do we qualify for, or should we consider, specialized fetal interventions like FETO?
  3. 3.Does the hospital where I will deliver have a Level IV NICU and ECMO capabilities?
  4. 4.Is the CDH considered 'isolated', or are there other genetic or structural findings we need to discuss?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

Related questions

Why Do CDH Survivors Need Multidisciplinary Clinics?Why Does CDH Cause Severe GERD and Feeding Issues?Will My Baby Outgrow Their CDH Patch? Risks & MonitoringCan CDH Surgery Be Done While on ECMO?Left vs. Right-Sided CDH: What Are the Differences?What is the FETO Procedure Timeline for CDH?What is Gentle Ventilation for CDH?How Does Congenital Diaphragmatic Hernia Affect Lungs?Will My CDH Child Have Asthma or Need Oxygen?What Are the Prenatal Genetic Testing Options for CDH?How is Pulmonary Hypertension Treated in CDH Babies?Does CDH Affect Your Child's Chest & Spine Growth?What Causes CDH? Did I Cause My Baby's Hernia?What Happens in the Delivery Room with a CDH Baby?What to Expect When Your Baby is on ECMO for CDHWhy is CDH Surgery Delayed? The Role of Stabilization

References

References (15)
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    A multicentre study to predict neonatal survival according to lung-to-head ratio and liver herniation in fetuses with left congenital diaphragmatic hernia (CDH): Hidden mortality from the Latin American CDH Study Group Registry.

    Cruz-Martínez R, Etchegaray A, Molina-Giraldo S, et al.

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    Improving the Prediction of Neonatal Outcomes in Isolated Left-Sided Congenital Diaphragmatic Hernia by Direct and Indirect Sonographic Assessment of Liver Herniation.

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    Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine 2016; (35(7)):1437-43 doi:10.7863/ultra.15.07020.

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    Secondary Imaging Findings Aid in Prenatal Diagnosis and Characterization of Congenital Diaphragmatic Hernia: Role of an Abnormal Orientation of Vascular Structures and Gallbladder Position.

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    Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine 2019; (38(6)):1449-1456 doi:10.1002/jum.14823.

    PMID: 30244484
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    Management advances for congenital diaphragmatic hernia: integrating prenatal and postnatal perspectives.

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    Antenatal assessment of liver position, rather than lung-to-head ratio (LHR) or observed/expected LHR, is predictive of outcome in fetuses with isolated left-sided congenital diaphragmatic hernia.

    Straňák Z, Krofta L, Haak LA, et al.

    The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 2017; (30(1)):74-78 doi:10.3109/14767058.2016.1163539.

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    Antenatal management and outcomes of pregnancies with congenital diaphragmatic hernia.

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    The diagnostic and predictive value of ultrasonography in congenital diaphragmatic hernia.

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    Antenatal predictors of outcome in prenatally diagnosed congenital diaphragmatic hernia (CDH).

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    The validity of the observed-to-expected lung-to-head ratio in congenital diaphragmatic hernia in an era of standardized neonatal treatment; a multicenter study.

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    Improved Survival in Left Liver-Up Congenital Diaphragmatic Hernia by Early Repair Before Extracorporeal Membrane Oxygenation: Optimization of Patient Selection by Multivariate Risk Modeling.

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    Optimal gestational age at delivery in isolated left-sided congenital diaphragmatic hernia.

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This page explains CDH prognosis based on liver position for educational purposes only. Always consult your maternal-fetal medicine specialist or pediatric surgeon regarding your baby's specific diagnosis, O/E LHR, and treatment plan.

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