Review for 10.1186/s12876-021-01997-x (2021)

Reviewer’s report
Title: 
A Case of Primary Intestinal Lymphangiectasia with non-Hodgkin
Lymphoma
Version: 
0 
Date: 
18 May 2021
Reviewer's report:
The authors present an interesting case of a patient with intestinal large cell B-
cell lymphoma and preceding protein loss and thickened small bowel loops. The
authors make a diagnosis of primary intestinal lymphangiectasia. A review on
literature on lymphoma in patients with primary intestinal lymphangiectasia is
further included.
This paper is well written with relevant images.
However, the images 
of terminal iluem show a nodular mucosa, presumably of
lymphatic origin. Histology shows dilated lymphatic vessels. This seems rather
due to secondary lymphangiectasia associated with lymphoma. The typical
endoscopic feature of whittish, dilated villi is missing. In my opinion, this case
cannot support the hypothesis of primary lymphangiectasia being a risk factor
for development of lymphoma.
In summary, an interesting case of presumably secondary lymphangiectasia in
small bowel lymphoma is reported. The discussion and literature research should
be on the wide field of differential diagnoses to secondary lymphangiectasia. The
discussion could also include feature of both, primary and secondary
lymphangiectasia.
However, this case cannot be the trigger for a systematic review and not an
additional case to support the hypothesis of primary intestinal lymphangiectasia
being a potential cause of lymphoma insteaad of just being a epiphenomen of
lymphoma. To do so, endoscopic diagnosis in the upper small bowel with dilated
lymphatic vessels in enlarged whittish villi and the absence of lymphoma in total
enteroscopy, either by capsule endoscopy or device assisted enteroscopy would
be mandotory in the early state of disease.
In 2021 the authors claimd that since the first description of primary intestinal
lymphangiectasia only 200 cases have been published. However, this evidence is
from a report published in 2010. This number is not supposed to be still correct
today, especially when considering the massive improvement of small bowel
endoscopy in the last years.
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
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from apparent manipulation?
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