Helical Computed Tomography Data Research Articles

Reconstruction of Fronto-Orbital and Nasal Defects With Compound Epoxied Maleic Acrylate/Hydroxyapatite Implant Prefabricated With a Computer Design Program

The repair of fronto-orbital nasal bone defects may be a troublesome problem to plastic surgeons. This report aims to present the results of reconstruction of fronto-orbital nasal bone defects with the prefabrication of epoxied maleic acrylate/hydroxyapatite compound (EH compound) using 3-dimensional (3D) imaging data and computer-assisted manufacturing techniques, sometimes combined with autogenous bone to repair nasal defect. Helical computed tomography data were used to create a 3D model of the patient's skull. On the basis of these data, the individual shape of the implant was created by a computer-aided design/computer-aided manufacturing program. A rapid prototyping system was applied for production of the physical models. A total of 12 patients with traumatic fronto-orbital nasal defects were included in this study. The patients followed up for 1 to 24 months. The satisfactory results, such as excellent symmetry, stability, and normal fronto-orbital contours were obtained for all patients. The operating time was short without any complications. The depression of the region of fronto-orbital nasal bone defects always achieved an attractive or satisfactory prominence that was in balance and harmony with other facial features of all the patients. This method allows accurate fabrication of the implant. It improves the surgical techniques and reduces the risk of a second intervention, with improved aesthetic outcomes.

An algorithm for efficient metal artifact reductions in permanent seed implants

Purpose:In permanent seed implants, 60 to more than 100 small metal capsules are inserted in the prostate, creating artifacts in x‐ray computed tomography (CT) imaging. The goal of this work is to develop an automatic method for metal artifact reduction (MAR) from small objects such as brachytherapy seeds for clinical applications.Methods:The approach for MAR is based on the interpolation of missing projections by directly using raw helical CT data (sinogram). First, an initial image is reconstructed from the raw CT data. Then, the metal objects segmented from the reconstructed image are reprojected back into the sinogram space to produce a metal‐only sinogram. The Steger method is used to determine precisely the position and edges of the seed traces in the raw CT data. By combining the use of Steger detection and reprojections, the missing projections are detected and replaced by interpolation of non‐missing neighboring projections.Results:In both phantom experiments and patient studies, the missing projections have been detected successfully and the artifacts caused by metallic objects have been substantially reduced. The performance of the algorithm has been quantified by comparing the uniformity between the uncorrected and the corrected phantom images. The results of the artifact reduction algorithm are indistinguishable from the true background value.Conclusions:An efficient algorithm for MAR in seed brachytherapy was developed. The test results obtained using raw helical CT data for both phantom and clinical cases have demonstrated that the proposed MAR method is capable of accurately detecting and correcting artifacts caused by a large number of very small metal objects (seeds) in sinogram space. This should enable a more accurate use of advanced brachytherapy dose calculations, such as Monte Carlo simulations.

Positional Reproducibility of Pancreatic Tumors Under End-Exhalation Breath-Hold Conditions Using a Visual Feedback Technique

To assess positional reproducibility of pancreatic tumors under end-exhalation (EE) breath-hold (BH) conditions with a visual feedback technique based on computed tomography (CT) images. Ten patients with pancreatic cancer were enrolled in an institutional review board-approved trial. All patients were placed in a supine position on an individualized vacuum pillow with both arms raised. At the time of CT scan, they held their breath at EE with the aid of video goggles displaying their abdominal displacement. Each three-consecutive helical CT data set was acquired four times (sessions 1-4; session 1 corresponded to the time of CT simulation). The point of interest within or in proximity to a gross tumor volume was defined based on certain structural features. The positional variations in point of interest and margin size required to cover positional variations were assessed. The means ± standard deviations (SDs) of intrafraction positional variations were 0.0 ± 1.1, 0.1 ± 1.2, and 0.1 ± 1.0 mm in the left-right (LR), anterior-posterior (AP), and superior-inferior (SI) directions, respectively (p = 0.726). The means ± SDs of interfraction positional variations were 0.3 ± 2.0, 0.8 ± 1.8, and 0.3 ± 1.8 mm in the LR, AP, and SI directions, respectively (p = 0.533). Population-based margin sizes required to cover 95th percentiles of the overall positional variations were 4.7, 5.3, and 4.9 mm in the LR, AP, and SI directions, respectively. A margin size of 5 mm was needed to cover the 95th percentiles of the overall positional variations under EE-BH conditions, using this noninvasive approach to motion management for pancreatic tumors.

A Method for Reconstructing the Arterial Input Function during Helical CT: Implications for Myocardial Perfusion Distribution Imaging

To determine if a multidetector computed tomographic (CT) image acquisition and analysis method can enable accurate measurement of the arterial input function (AIF) during first-pass adenosine stress helical multidetector CT angiography and to test the effect of using this method on the semiquantitative assessment of myocardial perfusion distribution. The animal care and use committee of Johns Hopkins University approved the use of all procedures. The AIF was reconstructed by using a combination of bolus-tracking and time-registered helical multidetector CT data. After the AIF reconstruction method was validated in healthy animals, coronary stenosis was induced in seven dogs and contrast material-enhanced multidetector CT was performed during adenosine infusion (0.14-0.21 mg per kilogram of body weight per minute). Myocardial attenuation density (AD) parameters normalized to portions of the AIF were compared with microsphere myocardial blood flow (MBF) measurements at linear regression analysis. There was no significant difference between the area under the curve (AUC) for dynamic multidetector CT-derived AIF (3108 + or - 1250 [standard deviation]) and that for combined bolus-tracking and time-registered multidetector helical CT-derived AIF (3086 + or - 941) (P = .90). When AIF analysis was applied to helical multidetector CT myocardial perfusion measurements, the correlation between MBF and mean myocardial AD normalized to the AUC for the entire AIF was significant (R(2) = 0.82, P <.001). Myocardial AD normalized to the AUC for the AIF measured during helical multidetector CT correlated best with MBF (R(2) = 0.86, P <.001). The combination of bolus tracking and time-registered helical imaging enables reconstruction of the AIF during multidetector CT perfusion imaging. The helical CT AIF can be used to improve the semiquantitative assessment of myocardial perfusion distribution.

Fast iterative reconstructions for animal CT

For iterative x-ray computed tomography (CT) reconstruction, the convex algorithm combined with ordered subset (OSC) [1]is a relatively fast algorithm and has shown its potential for low-dose situations. But it needs one forward projection and two backprojections per iteration. Unlike convex algorithm, the gradient algorithm only requires one forward projection and one backprojection per iteration. Here, we applied ordered subsets of projection data to a modified gradient algorithm. In order to further reduce computation time, the new algorithm, the ordered subset gradient (OSG) algorithm, can be adjusted with a step size. We also implemented another OS-type algorithm called OSTR. The OSG algorithm is compared with OSC algorithm and OSTR algorithm using three-dimensional simulated helical cone-beam CT data. The performance is evaluated in terms of log-likelihood, contrast recovery, and bias-variance studies. Results show that images of OSG has compatible visual image quality to those of OSC and OSTR, but in the resolution and bias-variance studies, OSG seems to reach stable values with faster speed. In particular, OSTR has better recovery in a smoother region, but both OSG and OSC have better recovery in the high-frequency regions. Moreover, in terms of log likelihood with respect to computation time, OSG has faster convergence rate than that of OSC and similar to that of OSTR. We conclude that OSG has potential to provide comparable image quality and is more computationally efficient, and thus could be suitable for low-dose, helical cone-beam CT image reconstruction.

Customized design and manufacturing of chin augmentation implant based on reverse engineering and rapid prototyping

目的 探讨应用反求工程与快速成型技术对小颏畸形进行整复设计和置入体制作的可行性.方法 对2例小颏畸形患者,利用X线头影测量方法分析患者畸形类型和严重程度,并计算出需要恢复的数据,在计算机上用反求工程软件在患者下颌骨颏部点云数据上恢复出正常的骨性外形,快速成型制作个体化置入体,并实施衬垫颏成形术.结果 手术过程顺利,置入体精密就位,术后外形达到了术前设计的预期效果.术后X线头影测量对比分析显示:上唇高度与下唇颏高度之比为0.45.面中与面下1/3之比为0.94,颏颈角、FH-N'-Pg角、颏唇沟深度、面形角等面部测量参数改善明显.结论 反求工程与快速成型技术可用于小颏畸形整复的设计和置入体的制作,为面部类似畸形整复开辟了新的途径。

Four-dimensional proton treatment planning for lung tumors

In proton radiotherapy, respiration-induced variations in density lead to changes in radiologic path lengths and will possibly result in geometric misses. We compared different treatment planning strategies for lung tumors that compensate for respiratory motion. Particle-specific treatment planning margins were applied to standard helical computed tomography (CT) scans as well as to "representative" CT scans. Margins were incorporated beam specific laterally by aperture widening and longitudinally by compensator smearing. Furthermore, treatment plans using full time-resolved 4D-computed tomography data were generated. Four-dimensional treatment planning guaranteed target coverage throughout a respiratory cycle. Use of a standard helical CT data set resulted in underdosing the target volume to 36% of the prescribed dose. For CT data representing average target positions, coverage can be expected but not guaranteed. In comparison to this strategy, 4D planning decreased the mean lung dose by up to 16% and the lung volume receiving 20 Gy (prescribed target dose 72 Gy) by up to 15%. When the three planning strategies are compared, only 4D proton treatment planning guarantees delivery of the prescribed dose throughout a respiratory cycle. Furthermore, the 4D planning approach results in equal or reduced dose to critical structures; even the ipsilateral lung is spared.

Customized design and manufacturing of chin implant based on rapid prototyping

Purpose – To develop a computer‐assisted prefabricated implant design and manufacturing system to improve the esthetic outcome in chin surgery.Design/methodology/approach – Design methods for medical rapid prototyping (RP) of custom‐fabricated chin augmentation implant are presented in this paper. After a careful preoperative planning based on cephalometric tracing for esthetic assessment, helical computed tomography data were used to create a three‐dimensional model of the deficient mandible. Based on these data, the inner surface of the prosthesis was designed to fit the bone surface exactly. The outer geometry was generated from a dried human mandible to create anatomically correct shape prosthesis. The inner and outer surfaces were then connected, and a solid model resulted. A RP system was used for production of the physical models. The surgical planning was performed using the implants and skull models. The resulting SLA implant is used for the production of a mold, which is used to cast the titaniu...

Three‐dimensional helical computed tomography cholangiography with minimum intensity projection in gallbladder carcinoma patients with obstructive jaundice: Comparison with magnetic resonance cholangiography and percutaneous transhepatic cholangiography

Computed tomography (CT) is traditionally used for evaluation and staging of gallbladder carcinoma (GC). However, in the subgroup of patients with obstructive jaundice, magnetic resonance cholangiography (MRC) is generally required to assess the level of biliary obstruction. The present study was undertaken to evaluate the diagnostic potential of three-dimensional helical CT cholangiography (3-D CTC) with minimum intensity projection (minIP), to determine the presence and level of biliary obstruction. Twenty-five consecutive patients with proven GC, presenting with clinical and biochemical features of obstructive jaundice, over a 1-year period were included in the study. Dual phase helical CT data was obtained in the arterial and venous phases, respectively, after intravenous contrast injection using a pressure injector. Axial CT data (both arterial and venous phase) was studied for staging and resectability of tumor. Three-dimensional helical CT cholangiography using minIP obtained from the venous phase data set, was used to assess the level of biliary obstruction and isolation of hepatic segmental ducts. Three-dimensional helical CT cholangiography findings were compared with MRC and percutaneous transhepatic cholangiography (PTC) (gold standard). None of the patients were operated on as they were all considered inoperable on axial CT images due to extensive local disease or distant metastasis. In all patients, 3-D CTC demonstrated dilated intrahepatic ducts up to tertiary branch level. The 3-D CTC correctly diagnosed the level of biliary obstruction and demonstrated isolated segmental ducts in all patients and correlated well in all cases with MRC and PTC findings in this regard. However, the 3-D CTC did not add any additional information over the axial source images. Three-dimensional helical CT cholangiography with minIP can correctly determine the level of biliary obstruction in patients with GC and may be a strong competitor with MRC, because it gives equivalent information with regard to the level of ductal obstruction even while being a part of an overall comprehensive CT staging study. Even though 3-D CTC did not provide additional information on top of the source images, the referring physicians found them very useful for conceptualization of the 3-D biliary anatomy.

Experiments for examination of precision (in CAS)

The question of precision of models in computer-assisted surgery was first discussed in the context of the use of computed tomography (CT) data for model fabrication by milling or stereolithography (STL) [Int. J. Oral Maxillofac. Surg. 24 (1995) 98, Dtsch. Z. Mund- Kiefer- Gesichts-Chir. 19 (1995) 221]. Since then, CT and other imaging procedures were fundamentally optimized. The physical prerequisites, however, are the same as 20 years before, i.e. a physical resolution of 0.5 mm principally limits the precision in CT and can only be optimized in little steps (CT) [Invest. Radiol. 29 (1994) 574, Int. J. Maxillofac. Surg. 24 (1995) 69, M. Wehmöller, H. Eufinger, A. Falk, W. Maβberg, E. Machtens, Reverse engineering methods for the determination of the precision of 3D helical CT data. In: Lemke, H.U., Inamura, K.U., Vannier, M.W. (Eds.), Computer Assisted Radiology and Surgery, CAR'97, Elsevier, Amsterdam (1997) p. 701]. Furthermore, biological conditions cannot be completely simulated in measurements performed with models since models cannot represent all the fine anatomical structures. Therefore, the interpretation of the images plays an important role in the further use in computer-assisted surgery.

Renal cyst pseudoenhancement: evaluation with an anthropomorphic body CT phantom.

To determine the effects of cyst diameter and location (intrarenal, exophytic), renal attenuation, section collimation, and computed tomographic (CT) interscanner variability on renal cyst pseudoenhancement in a phantom model. A customized anthropomorphic phantom was designed to accept 40-, 140-, and 240-HU renal inserts containing intrarenal and exophytic 7-, 10-, and 15-mm cysts. Each phantom and insert were scanned with five different helical CT scanners by using 1.0-1.5-mm, 2.50-3.75-mm, 5.0-mm, 7.0-8.0-mm, and 10.0-mm section collimation. Means and SDs of CT number measurements were obtained for each cyst within each variably "enhanced" renal insert. Mixed-model analysis of variance accommodating heteroscedasticity of data was used to assess the effect of scanner type, section collimation, and cyst diameter on cyst attenuation. Pseudoenhancement (range, 10.3-28.3 HU), observed by using effective section collimation equal to or less than 50% of cyst diameter, occurred in 34 (38%) of 90 intrarenal cyst measurements. Pseudoenhancement was observed with all five CT scanners, though the magnitude of the effect was nonuniform. Significant interactions were noted between renal cyst diameter, background renal attenuation, and CT scanner type in terms of their effects on cyst attenuation. No appreciable pseudoenhancement was observed with exophytic cysts. Pseudoenhancement is maximal when small (< or = 1.5-cm) intrarenal cysts are scanned during maximal levels of renal parenchymal enhancement. The magnitude of this effect varies with scanner type but may be large enough to prevent accurate lesion characterization, despite use of a thin-section helical CT data acquisition technique.

Anti-aliasing weighting functions for single-slice helical CT

Spatially variant longitudinal aliasing plagues most volumes reconstructed from single-slice helical computed tomography data, and its presence can degrade resolution and distort image structures. We have recently developed a Fourier-based approach to longitudinal interpolation in helical computed tomography that can, for scans performed at pitch 1 or lower, essentially eliminate this longitudinal aliasing by exploiting a generalization of the Whittaker-Shannon sampling theorem whose conditions are satisfied by the interlaced pairs of direct and complementary longitudinal samples. However, the algorithm is computationally intensive and cannot be pipelined. In this paper, we address this shortcoming by deriving two spatial-domain, projection-data weighting functions that approximate the application of the Fourier-based approach, and preserve its aliasing suppression properties to some degree, while allowing for a pipelined implementation. The first approach, which we call simply 180AA, for anti-aliasing, is a direct spatial-domain approximation of the 180FT approach. The second approach, which we call 180BSP, is based on an approximate generalized interpolation approach making use of B-splines. Studies of aliasing and resolution properties in reconstructions from simulated data indicate that while the 180AA and 180BSP approaches do not perfectly replicate the favorable aliasing suppression and resolution properties of the 180FT approach, they do represent an improvement over the clinically standard 180LI approach on these fronts.

ECG-gated reconstructed multi-detector row CT coronary angiography: effect of varying trigger delay on image quality.

To evaluate the effectiveness of electrocardiographically (ECG)-gated retrospective image reconstruction for multi-detector row computed tomographic (CT) coronary angiography in reducing cardiac motion artifacts and to evaluate the influence of heart rate on cardiac image quality. Sixty-five patients with different heart rates underwent coronary CT angiography. Raw helical CT data and ECG tracings were combined to retrospectively reconstruct at the defined consecutive z position with a temporal resolution of 250 msec per section. The starting points of the reconstruction were chosen between 30% and 80% of the R-R intervals. The relationships between heart rate, trigger delay, and image quality were analyzed. Optimal image quality was achieved with a 50% trigger delay for the right coronary artery and 60% for the left circumflex coronary artery. Optimal image quality for the left anterior descending coronary artery was equally obtained at 50% and 60% triggering. A significant negative correlation was observed between heart rate and image quality (P <.05). The best image quality was achieved when the heart rate was less than 74.5 beats per minute. To achieve high image quality, the heart rate should be sufficiently slow. Selection of appropriate trigger delays and a decreasing heart rate are effective to reduce cardiac motion artifacts.

Pericaval fat collection mimicking an intracaval lesion on CT in patients with chronic liver disease.

Localized fat collections, which mimic fat-containing lesions of the inferior vena cava (IVC) on computed tomographic (CT) images, have been reported as rare incidental findings. Our goal was to evaluate the association of this CT finding with chronic liver disease. Sixty-one patients with chronic liver disease were prospectively studied with contrast-enhanced abdominal CT. The prevalence, attenuation, location, shape, and size of the pericaval fat collections were assessed. Multidirectional reformatted CT images were obtained from helical CT data to identify origins of the pericaval fat collections. Sixty-one patients without chronic liver disease were studied as control subjects. Pericaval fat collections were seen on abdominal CT in 16 (26.2%) of the 61 patients. On the reformatted images, the fat collections were contiguous to the fat tissue around the subdiaphragmatic esophagus in all 16 patients. The fat collections were located at the posterior aspect of the IVC in 12 patients. In the control group, pericaval fat collection mimicking an intracaval lesion was not seen. In patients with chronic liver disease, pericaval fat collections are not rare CT findings and their characteristic location is considered to be posterior to the IVC. It is important not to misinterpret such CT findings as abnormalities of the IVC, such as thrombus or tumors.

Iliac arterial injuries after endovascular repair of abdominal aortic aneurysms: correlation with iliac curvature and diameter.

To determine the relationship between iliac arterial tortuosity and cross-sectional area and the occurrence of iliac arterial injuries following transfemoral delivery of endovascular prostheses for repair of abdominal aortic aneurysms. Iliac arterial curvature values and orthogonal cross-sectional areas were determined from helical computed tomographic (CT) data acquired in 42 patients prior to transfemoral delivery of aortic stent-grafts. The curvature and luminal cross-sectional area orthogonal to the median centerline were quantified every millimeter along the median centerline of the iliac arteries. An indicator of global iliac tortuosity, the iliac tortuosity index, was defined as the sum of the curvature values for all points with a curvature of 0.3 cm(-1) or greater, and cross-sectional area (CSA) was indexed for all points as the mean cross-sectional diameter (D = 2 radical[CSA/pi]). Following stent-graft deployment, helical CT data were analyzed for the presence of iliac arterial dissections independently by two reviewers. Eighteen dissections were detected in 16 patients. The iliac tortuosity index was significantly larger in iliac arteries with dissections (35.5 +/- 20.8 [mean +/- SD]) when compared with both nondissected contralateral iliac arteries in the same patients (26.1 +/- 21.0, P =.001) and iliac arteries in patients without any iliac arterial injury (20 +/- 9, P =.009). The tortuosity index was higher ipsilateral to the primary component delivery in 10 of 11 iliac dissections that developed along the primary component delivery route. A high degree of iliac arterial tortuosity appears to impart greater risk for the development of iliac arterial injuries in patients undergoing transfemoral delivery of endovascular devices.

Development of virtual CT cholangiopancreatoscopy.

Endoluminal virtual computed tomographic (CT) cholangiopancreatoscopic views of the pancreatic and common bile ducts were generated in 16 patients by using helical CT data sets and endoscopic three-dimensional reconstruction images. In all patients with ductal dilatation, virtual images were obtained and findings correlated with those at helical CT and endoscopic retrograde cholangiopancreatography. Virtual CT cholangiopancreatoscopy is a feasible technique, and initial experience shows promising results.

An optimization problem in virtual endoscopy

This paper studies a graph optimization problem occurring in virtual endoscopy, which concerns finding the central path of a colon model created from helical computed tomography (CT) image data. The central path is an essential aid for navigating through complex anatomy such as colon. Recently, Ge et al. (1998) devised an efficient method for finding the central path of a colon. The method first generates colon data from a helical CT data volume by image segmentation. It then generates a 3D skeleton of the colon. In the ideal situation, namely, if the skeleton does not contain branches, the skeleton will be the desired central path. However, almost always the skeleton contains extra branches caused by holes in the colon model, which are artifacts produced during image segmentation. To remove false branches, Ge et al. (1998) formulated a graph optimization problem for obtaining the central path. This paper presents a refined formulation and justifies that the solution of the refined optimization problem represents the accurate central path of a colon. We then provide a fast algorithm for solving the problem.

Individual prostheses and resection templates for mandibular resection and reconstruction

This new technique uses helical computed tomography data and computer-aided design and manufacturing for preoperative fabrication of individual mandibular prostheses together with corresponding resection templates. Coherent 3D geometries for computer-based models are the basis for the construction of prostheses and provide data for a computerized numerical control fabrication. Fixation plates are fabricated with the titanium prostheses. The identical data of these plates are used for the computer-aided design and manufacturing of resection templates, which guide an oscillating saw in a precisely determined resection plane. This plane again is identical with the prostheses' margins for mandibular body replacement. The use of this technique in four patients is reported on: after temporary insertion of the templates for resection and after resection, the prostheses were stabilized with the same screws in the same screw-holes where the templates had been. Resection and reconstruction were thus highly precise, safe and fast and primarily led to excellent aesthetic and functional results. Wound-healing depends on a safe soft-tissue reconstruction over these large prostheses. Coverage with flaps seems obligatory. In spite of the superior technical aspects, the clinical long-term results of this new technique were poor.

Colorectal lesions: evaluation with CT colography.

Computed tomographic (CT) colography is a promising technique for differentiating malignant or premalignant colorectal disease from benign lesions. In this technique, helical CT data are used to produce reformated two-dimensional (2D) CT images and simulated endoscopic images of the colon. Adenomatous polyps 0.7 cm in diameter or larger are easily detected on CT colographic images: A pedunculated polyp is identified by means of its stalk, whereas a sessile polyp appears as a polypoid soft-tissue mass projecting into the air-filled lumen of the colon. However, flat adenomas (lesions raised less than 2 mm from the surface of the colon) are difficult to detect with CT colography. In cases of colorectal cancer, both intraluminal and extraluminal disease can be evaluated with CT colography. Although CT colography does not allow differentiation between hyperplastic and adenomatous polyps, lipomas can be confidently diagnosed because of their fatty attenuation on reformatted 2D images. Pseudolesions that can produce false-positive findings at CT colography include the ileocecal valve, retained stool, retained barium, respiratory artifacts, and a stool-filled diverticulum.

Pericaval fat collection that mimics thrombosis of the inferior vena cava: demonstration with use of multi-directional reformation CT.

To evaluate the causes for localized fat collection that seemed to be within the subdiaphragmatic inferior vena cava (IVC) on axial computed tomographic (CT) scans. Six consecutive patients with presumed intracaval fat collection at routine abdominal CT (n = 2) or thin-section CT of the lung (n = 4) were studied prospectively with helical CT. Three patients had chronic liver diseases. Multi-directional, two-dimensional, reformatted images were obtained from the helical CT data for identification of the relation between the IVC and fat collection. Six patients without intracaval fat collection were studied as control subjects. On axial CT scans, the fat collection had a round or oval shape (in four of six patients) and was located posteromedial to the IVC (in four of six patients). On coronal reformatted images, the fat collection was outside the IVC between the diaphragm and subdiaphragmatic IVC, which was contiguous to the fat around the subdiaphragmatic esophagus. In the fat collection group, the IVC angled toward the right and narrowed to half in diameter as it passed down to the diaphragm. In the control group, the IVC was straight, although the diameter decreased similarly. A localized fat collection adjacent to the subdiaphragmatic IVC that mimics intracaval fat on axial CT scans is due to acute angulation of the IVC, which is probably a result of anatomic variation, chronic liver disease, or both.