Review for 10.1186/1471-230X-13-42 (2013)

Reviewer's report
Title:Microscopic polyangiitis complicated with ileal involvement detected by
double-balloon endoscopy: a case report
Version: 1Date:5 September 2012
Reviewer: Jorgen Agnholt
Reviewer's report:
Review
BMC Gastroenterol:
Masashi Fukushima et al: Microscopic polangiitis complicated with ileal
inolvement detected by double-ballon endoscopy: a case report
The authors are presenting a paper on Microscopic polyangiitis with
gastrointestinal involvement detected by doiuble balloon endoscopy.
Design : The paper is based on a case presentation. At admission the patient
suffered from an acute abdominal event with paralytic ileus. She had had a
weight loss and during two years she was suffering from neurological
disturbances in the lower exstremities.
Malignant lymphoma was suspected since an abdominal CT showed small
intestinal edema. A DBE was performed disclosing ulcers in the small bowel and
a relative stenosis. Histology revealed signs of ischemia but no ethiology. No
signs of TB. Further examinations with nerve biopsy and renal biopsy showed
vasculitis. Due to the clinical picture and the nerve biopsies a diagnosis of MPA
was etstablished.
The paper rises some questions (major compulsory revisions): What are the new
information? The diagnosis was not established by endoscopy, but the
endoscopy disclosed findings that should be differentiated from – first of all –
Crohns disease (CD). The ulcers, the stenosis might as well had been derived
from a patient with CD. The description of the pathological findings should have
been described more thoroughly. Looking at the patholigical picture there are
significant amounts of inflammatory cells. What kind of cells are we talking
about? Did the authors find transmural inflammation? Could a diagnosis of
Crohns been excluded on the histology? Since the patient was controlled with
two endoscopies a pathological picture after treatment (in the same figure
(before/after) would have been informative)
No colonic changes were shown, but could the findings in the small bowel been
seen by intubation of the terminal ileum by the colonoscope (how many
retractions were necessary from the intubation of the valvula Baughini?
Discussion: What was the advantage in this paper using DBE. The discussion
should be focused on which contribution the endoscopy delivered in the present
case – was it necessary to perform a DBE or would a colonoscpy with tubulation
of ileum had been sufficient. Could the ulcers have been visualised by capsule
endoscopy or was the risk of retained capsule to high?
Artwork : before and after situations in same figures (pathology and endoscopy)
Renal biopsy and nerve biopsy in the same figure.
Conclusions : The present paper presents an interesting but rare case of
paralytic ileus where ulcers were detected in the small bowel. A number of
questions have been raised. The paper should been more focused on the
additive help of the DBE – in a patient where the MPA diagnosis was established
by the clinical picture and nerve + renal biopsy and not by the findings in the
small bowel. However the paper describes what gastrointestinal changes we
could expect to see in patient with small intestinal involvement, and that´s the
news.
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
no financial or non financial competing interests