Review for 10.1186/1471-230X-10-75 (2010)

Reviewer's report
Title:Case report: Acute Pancreatitis Caused By Postcholecystectomic
Hemobilia.
Version: 3Date:9 February 2010
Reviewer: Michael Kelly
Reviewer's report:
Major Compulsory Revisions
This is a nice case report discussing acute pancreatitis due to haemobilia after
cholecystectomy. It states that this is the first time it has been described.
The section describing the case is poor. It would be useful to have details about
the original operation- was it difficult? Also was the bile duct imaged either
intraop or preop.
The biochemical data does not state the normal range for their lab or even the
units used.
After the patient was found to have active bleeding through the papilla at
endoscopy why wasn’t angiography carried out straight away? The patient went
on the have an ERCP and sphincterotomy. There is always a risk of bleeding
from sphincterotomy potentially making things worse.
The description of the technique used for angioembolisation is one sentence
“Selective angiography revealed a psoudoaneurisma of right hepatic artery
connected to remaining cystic duct and Angioembolisation was made at the
same intervention”
In my opinion it is not appropriate to omit details of the technique- e.g. sheath
used for cannulation, catheters, type of coils…
And details of the manufacturers
There is no mention of follow up of the patient or rescan to check the aneurysm
has not reformed. If there is followup how long is it since procedure?
The spelling and grammar is very poor. While I understand English may not be
the authors first language it is easy to run a spell check on a word program.
There are 8 authors; this is too many for a case report. Did they all meet the
requirements for authorship as below?
Authorship credit should be based on 1) substantial contributions to conception
and design, acquisition of data, or analysis and interpretation of data; 2) drafting
the article or revising it critically for important intellectual content; and 3) final
approval of the version to be published. Authors should meet conditions 1, 2, and
3. (International Committee of Medical Journal Editors, 2009).
There are no figure legends in the manuscript. There are too many figures with
duplication. The patient’s name is visible on the CT. It has not been cropped or
labelled and is not of very good quality.
I feel that there are too many references (11) for a case report.
There is no statement saying that the patient gave consent for the case report.
There has been no description of the embolisation technique and while I
understand that the authors purpose was to report a new complication rather
dwell on embolization it should still be covered. It appears that they have
dropped coils only partially into the aneurysm and mainly into the proximal right
hepatic artery. This has “closed the front door” without “closing the back door”
and leaves the potential for the aneurysm to refill from collaterals (then it is not
possible to reach it endovascularly). Sometimes this has to be an acceptable
compromise, but closing both front and back doors should be attempted first (if
not done, why not?). Also on the last image there indeed appears to be some
filling of the pseudo-aneurysm from collaterals but no mention of this was made
in the report.
The main point of the article is that bleeding into the bile duct caused
pancreatitis. I accept there was abdominal pain and raised amylase but was
there pancreatitis on CT scan? - The images are too poor for me to see. It is
stated that the bile duct was 18 mm at ERCP. It takes a reasonable time for a
bile duct to dilate up so it seems hard to attribute the dilated bile duct to an acute
bleed. Similarly the bilirubin level was 8 (presumably mg/dL) with (6.2 conjugated
or direct reacting) and this is high- again it takes time for a level such as that to
occur. Was the duct dilated pre or peri laparoscopic cholecystectomy? Is it
possible that there was a retained bile duct stone, could this have caused the
jaundice and pancreatitis. The clinical details do not mention how long the patient
had had abdominal pain and jaundice prior to presentation with bleeding. I guess
it is possible that the patient may have had a herald bleed weeks before the
presentation. While the authors’ judgement has to be respected maybe they
could discuss these unusual facts i.e. dilated bile duct and acute bleeding.
In my opinion the report needs to be improved before being reassessed. It may
be beneficial to turn it into a care report and review of the literature especially as
there are 8 authors to do the extra work.
Level of interest: An article of limited interest
Quality of written English: Not suitable for publication unless extensively edited
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
'I declare that I have no competing interests'