Review for 10.1186/s12876-021-01980-6 (2021)

Reviewer’s report
Title: 
Direct oral anticoagulants increase bleeding risk after endoscopic
sphincterotomy: A retrospective study
Version: 
1 
Date: 
19 May 2021
Reviewer's report:
The authors explored the risk factors for bleeding after EST in patients on
DOAC and evaluated the Japan Gastroenterological Endoscopy Society (JGES)
guidelines in patients undergoing antithrombotic treatment.
They presents DOAC treatment, low platelet count, and old age were significant
predictors of EST bleeding and proved the validity of JGES guidelines.
This is a well written, interesting paper, and useful contributing to clinical
practice.
However, I would like to suggest some issues with several comments and
criticisms as follows;
Comment 1:
All DOACs are affected by renal function.
Could you add the details to Table.1 and Table.5 regarding the presence of renal
dysfunction and the GFR value?
Comment 2:
Page 5, line 100:
In this study, DOAC was typically discontinued for <2 days based on the JGES
guidelines. 
On the other hand, when did the authors restart DOAL after EST or EPLBD?
The authors needs to clarify this point.
Comment 3:
Page 7, line 160-161:
This study also included patients who performed EPLBD as a papillary
procedure.
The authors should describe the detail of EPLBD procedure in the Method
session.
Comment 4:
There were 12 patients (28.6%) adapted Heparin replacement in No-drug group
(Table 2).
These patients should be included in DOAC group.
Moreover, for the 12 patients who indicated Heparin replacement, the APTT
value before EST should be described.
Comment 5:
Page 8, line 184:
Please revise 20.0% (2/15) to 20.0% (3/15).
Comment 6:
Figure 2
The authors showed overall treatment for EST bleeding.
Were there significant difference in the number of Endoscopic treatment for EST
bleeding between the DOAC group and No-drug group?
Could you evaluate the treatments for EST bleeding in the two groups
separately.
Comment 7:
Page 9, line 208-209:
Page 10, line 216-217:
There were 8 (33.3%) and 4 (22.2%) patients who had a combination of
antiplatelet drugs and DOAC in the <2-day group and ≥2-day group, respectively
(Table 5).
Could you add the detail of this point (ex, drug type, cessation period, and
resumption time, etc).
Comment 8:
Table 5
JGES guideline 2017 suggests that DOAC can be cessation on the day of
treatment when performing high-risk of bleeding (EST).
Since the purpose of this study is to evaluate the JGES guidelines for
gastroenterological endoscopy in patients receiving DOAC, how about dividing
the DOAC cessation period into two groups, <1-day group and ≥1-1day group.
Comment 9:
Page 11, line 246-248:
The authors considered that the low platelet count was caused by infection. Is
there any evidence to support that finding? (ex, rate and severity of cholangitis).
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