Stomach or bowel beside the heart with mediastinal shift; the prognosis is in the observed/expected lung-to-head ratio (O/E LHR) and whether the liver is up in the chest.
Orient first
- Left-sided in most; the stomach in the chest is the usual clue.
- Liver herniation and a low O/E LHR predict pulmonary hypoplasia and poor survival.
- Associated anomalies and karyotype change counselling.
Acquire the study
- Transabdominal ultrasound: four-chamber view, sagittal and coronal views of the thorax and upper abdomen; colour Doppler of the umbilical and hepatic veins.
The manoeuvre
- Four-chamber view: heart shifted; stomach or bowel beside it.
- Contralateral lung area on the four-chamber view (longest diameter × perpendicular diameter in mm) divided by head circumference = LHR; O/E LHR in %.
- Liver position: hepatic vessels (umbilical vein course, ductus venosus) above the diaphragm on colour Doppler.
- Other anomalies and liquor.
What confirms it
- Abdominal viscera in the thorax with mediastinal shift.
What licenses you to exclude it
- A normal four-chamber view with the stomach below the diaphragm excludes a large CDH; small right-sided hernias can be missed.
The classic misread
- Missing a right CDH, where the herniated liver looks like lung.
- Measuring the ipsilateral instead of the contralateral lung for the LHR.