Talk:WikiJournal of Medicine/Acute gastrointestinal bleeding from a chronic cause: a teaching case report
Authors: Michaël R. Laurent[i] , Lode Van Overbeke
Laurent, M; Van Overbeke, L.
Comments by Gwinyai Masukume, MB ChB(UZ), Dip Obst(SA), MSc(Wits)
These comments refer to this previous version of the article
Dear Drs Laurent and Van Overbeke,
RE: Acute gastrointestinal bleeding from a chronic cause: a teaching case report
We apologise for the delay in processing your article, the journal was enhancing its internal peer review mechanisms. Please find some editorial comments:
Thank you for submitting your article which illustrates the importance of intravenous fluid resuscitation and other issues.
1) We request that each co-author include their ORCID http://orcid.org/.
I have included my ORCID. My co-author does not have one and does not wish to create an ORCID account necessarily.
2) While your article is pitched for an internal medicine audience, the WikiJournal of Medicine is a general biomedical journal. We therefore encourage you to make the article as understandable to a broad medical audience as possible because there is substantial overlap between medical specialities. For example, you mention the normal range of the hepatic venous pressure gradient, we suggest you include in parentheses the normal reference limits for other clinical and laboratory variables. This would help clarify e.g. a temperature of 36.5°C – was this axillary, oral, etc. temperature?
I've added normal range for some clinical and biochemical parameters, others were already stated as normal. If additional changes are suggested please let me know.
3) If possible, with written informed consent of the patient, anonymized images showing the features you describe would be useful because they could be used to enhance other Wikimedia sites like Wikipedia.
We've considered this possibility but unfortunately no images are digitally available.
4) We also suggest a consistent style, e.g “… ambulance to the emergency room with haematemesis and red blood loss per anum.” Here, technical and non-technical terms are apparently mixed. Haematemesis could be described as vomiting blood since haematochezia was not used for red blood loss per anum.
The description was altered, patient had melena. I made some changes to avoid technical jargon, if more changes are suggested please let me know.
5) Although your article occurs in stages (perhaps to facilitate learning), please may you also prepare a single page version.
Yes indeed, the aim of this format is the facilitate learning, as similar formats in NEJM, BMJ and other journals use. For publication purposes, please find a single-page version which could be used to convert into a PDF [[Talk:Draft:WikiJournal of Medicine/Acute gastrointestinal bleeding from a chronic cause: a teaching case report/single|here]].
6) In addition to the conflict of interests declared, we suggest that the corresponding author declares involvement in Wikimedia projects as a potential conflict of interest.
Agreed, thank you for this suggestion and apologies for this incompleteness.
7) Please may you identify Wikipedia articles that might benefit from material presented in your paper. Upper gastrointestinal bleeding for example?
I used some content to improve the w:Portal hypertension article which is really the topic of this case report. Also I believe this work could serve as a teaching material for Wikiversity School of Medicine.
We are in the process of finding peer reviewers for your article. Thank you for submitting your article to us.
Thank you very much for feedback and efforts.
January 1st 2017.
External peer review 1
anonymous peer reviewer ,
This review refers to this previous version of the article
I have "no conflicts of interest in reviewing this work".
A very nice case. Some helpful suggestions are included below:
- The format of the article may be not "user friendly"as it consists of 4 part. In order to make it more user friendly you can add to the title (1 of 4) and so on. This would make it easier for the reader and perhaps for later citation in other literature. This is of particular importance especially in the pdf format.
Thank you for this suggestion, we have merged the main version of the article into a single-page document as per your suggestion.
- A subtitle of "Summery" need to be added before the first paragraph.
Thank you for this excellent suggestion. However this is not consistent with the current Journal style, as per recently published papers. This is something that could be considered as a more general suggestion for the journal, but not specific to this article.
- The first paragraph mentions that "the paper is aimed at an internal medicine readership".
I think it is expected to be helpful for other specialties as family medicine, surgery, and radiodiagnosis.
Although the article undoubtedly contains elements useful for many specialties, it is written and focused particularly on a junior internal medicine readership. The final diagnosis i.e. idiopathic non-cirrotic portal hypertension also lies within this field.
- Some suggestions added in bold/italic:
- His medication included a β-blocker, a statin, low-dose aspirin, an angiotensin receptor blocker and a proton pump inhibitor (PPI).
- Lab results were normal except for slight thrombocytopenia (141'000 platelet/µL; normal range 150'000-450'000 platelet/µL) and lymphocytosis (21'675 cell/µL, normal range 1'200-3'600 cell/µL with smudge cells, 17'700 cell/µL monoclonal B-lymphocytes).
- Short answers: Which risk factors for bleeding does this patient have? His age (≥75 years), low-dose aspirin treatment and prior gastric ulcer bleeding with Billroth II gastrectomy.
- This patient's risk of VTE should be weighed against the risk of bleeding, which is also elevated in this patient. Recommended strategies for the prevention of GI bleeding include PPIs and Helicobacter pylori eradication -if indicated- prior to starting oral anticoagulants.
- Gastroscopy and biopsies showed an inflammatory pseudopolyp at the gastro-oesophageal suture line of the Billiroth surgery and hyperaemic gastric mucosa with negative immunohistochemistry for Helicobacter pylori. Subsequently, a vitamin K-antagonist was added to prevent recurrent thromboembolic events. Low-dose aspirin was continued after discussion with the patient and his cardiologist.
- One week later, while INR was 2.5 (target 2.0 - 3.0 therapeutic range for vitamin K-antagonists), he was brought by ambulance to the emergency room because of blood vomiting (haematemesis) and passage of dark sticky offensive stool (melena). The patient denied drinking alcohol or taking non-steroid anti-inflammatory drugs.
- Repeat endoscopy the next day revealed oozing from fundal and oesophageal varices which were treated with ligation. A somatostatin analogue drip and prophylactic ceftriaxone were administered.
- Hepatitis B and C viruses serology, immunoglobulins including( antinuclear-, anti-smooth muscle- and anti-mitochondrial antibodies), α1-antitrypsin and ceruloplasmin were normal. Ultrasonography and computed tomography of the abdomen and magnetic resonance cholangiopancreatography showed emboligenic right kidney infarction but a normal liver, spleen (11 cm long), pancreas and portal veins.
- Portal hypertension is assessed by the hepatic venous pressure gradient (HVPG). An HVPG of 1 to 5 mmHg is normal. Portal hypertension is defined as HVPG ≥ 6 mmHg, but this usually only becomes clinically significant ≥ 10 mmHg when varices start developing. From 12 mmHg HVPG, ascites may develop and there appears to be a risk of variceal bleeding, while from 16 mmHg a risk ofhepatic decompensation and mortality has been noted. Also other methods of assesment include portal vien dupplex and portal vien diameter (affected by time of relation to meals.
We have made many grammar changes as per your suggestion, with the following exceptions:
- We have left the quantification that "older" age is a risk factor for bleeding.
- Although melena is typically indeed sticky and offensive, this was not reported by the patient and not noted in the patient's file, hence we cannot include it in this case report.
- We did not use a somatostatin analogue.
- Immunoglobulins were simply removed as not so relevant.
- Other non-invasive measurements of portal flow etc. were added but the effect of meal times was not included, we did not consider this relevant in the overall article.
- The reference of the bold italic statement need to be added otherwise it needs revision:
- Esophageal varices are almost always due to cirrhosis. In this case however, biochemical and imaging findings do not indicate cirrhosis, suggesting non-cirrhotic portal hypertension. A liver biopsy can definitively exclude cirrhosis. When performed via the transjugular route, the portosystemic venous pressure gradient can be measured during the same session to confirm portal hypertension and whether or not it results from presinusoidal, sinusoidal or a post-sinusoidal cause.
A reference was added.
- Table 1 does not appear in the pdf form of the article from this link: link
That is correct; our Table presents a simplified, more user-friendly version based on the reference cited. That version may be more academic but much, much more difficult to use and understand, so from a learning/teaching perspective we prefer this version.
- How frequent is the association?
- Chronic lymphocytic leukaemia (CLL) is not uncommon in elderly subjects and does not require specific therapy unless it causes symptoms e.g. from secondary cytopenia, B symptoms, splenomegaly or when there is a rapid increase in lymphocyte counts. CLL has been associated with idiopathic non-cirrhotic portal hypertension, ascites and hepatorenal syndrome although the incidence of portal hypertension as well as any causal relationship or the benefit of haematological treatment remains uncertain.
That is the million dollar question -but nobody knows, therefore this information cannot be added. More studies are needed. A specification that the incidence of INCPH in CLL remains unknown was added.
- The article might need to be put in one page of pdf file.
Done, see above.
Thank you for your feedback and apologies for the delay in responding.
Comment on reply
Thanks for your reply. I am not sure how to handle the wiki-syntax so here you are my reply. I am glad about the current version and satisfied about all changes except one point that need further discussion. All doctors are busy. I suggest that the editors should send reminding alerts on frequant basis.
- I think that what is used in GI bleeding is Octeriotide which is a somatostatin analog. I am aware of just one company producing it as Sandostatin. It is labled as a "Somatostatin analog", check this website linksandostatin. I assumed that your hospital used this medication. We can not refer to any analog by the original name of the hormone whatever was their resemblance. For example Hydrocortisone and Dexamethasone can be considered as analogs of Cortisol. Although they share high chemical resemblance features, but the three compounds are not he same chemically and differ clinically in their pharmacologic effect, e.g. half life, antiinflammatory strength, mineralcorticoid effect, glucocorticoid effect among other differences. I would appreciate to update me if you have the original Somatostatin hormone available in your hospital and sharing how you prescribe it. May be Octeriotide is famous as Somatostatin in some medical circles but it is a Somatostatin analog. Also, after searching on web seems there are other Somatostatin analogs as Octereotate Octreotate, pasireotide, lanreotideList of Somatostatin and somatostatin analogs. I think Somatostatin would have a short T1/2 as all natural hormones. Most probably a somatostatin analog was used. Please update me. Otherwise the article is mature and is ready for publishing as an addition to medical knowledge.--Ashashyou (discuss • contribs) 19:38, 9 April 2017 (UTC)
you are right that in most cases and internationally, octreotide (somatostatin analog) is used. However in this case (at that time and in this specific hospital, we confirm that actual somatostatin (and not Sandostatin) was used. This is commercially available in Belgium. It indeed has a shorter half-life but since we (used to) give it as a continuous infusion this is not a problem.
- Thanks for clarification. I am indebted for updating my knowledge. As i mentioned before "the article is mature and is ready for publishing as an addition to medical knowledge". It would be nice if you could give a hint about the somatostatin used in this case, as i think most readers would assume it to be somatostatin analogue, if possible. Good luck--Ashashyou (discuss • contribs) 20:25, 2 August 2017 (UTC)
Minor edit for reference consistency
Hello! With this edit, I found and added DOIs to the remaining reference articles that did not have them listed. I also tried to make the ISO 4 journal abbreviations consistent across citations. If you disagree with any elements of the edit, please feel free to change them back to the way they were. Thanks! Bobamnertiopsis (discuss • contribs) 19:44, 15 June 2017 (UTC)
- Hello! Thank you for adding missing DOIs and providing consistency. We welcome your helpful contributions, please feel free to continue. Thanks! Ear-phone (discuss • contribs) 09:37, 22 June 2017 (UTC)
External peer review 2
Following are comments from a physician and professor in clinical hepatology, who wants to remain anonymous. We can regard the peer review to have no conflicts of interest. Mikael Häggström (discuss • contribs) 20:01, 13 July 2017 (UTC)
anonymous peer reviewer ,
This review refers to this previous version of the article
Overall, the case report in interesting but the final conclusion has the potential to give misleading information, because of the rarity of CLL-associated cirrhosis (which obviously is not proven here).
We would like to thank the Reviewer for feedback. We agree that the association between CLL and non-cirrhotic portal hypertension is rare and causality has not yet been proven. We amended the conclusion of our case report, leaving out the emphasis on CLL, to:
- Our case report reminds physicians to consider the possibility of portal hypertension or its complications (including variceal bleeding, ascites or otherwise unexplained thrombocytopenia) in patients with suggestive symptoms even if they do not have cirrhosis, especially in the presence of potential causes of non-cirrhotic portal hypertension.
And the final diagnosis was also phrased more cautiously, to:
- Variceal bleeding due to idiopathic non-cirrhotic portal hypertension, possibly associated with chronic lymphocytic leukemia..
There is also misleading, or at least insufficient information about the treatment of bleeding varices. Here recent international guidelines need to be mentioned and referred to. It is puzzling that terlipressin which is more effective than octreotide is not mentioned at all.
We have now added a discussion of the appropriate management of bleeding varices, including reference to recent international guidelines on this topic. Indeed terlipressin is the standard of care and we currently also use this in our institution, but not at the time of this case report.
Also, the esophageal varices were treated with ligation, but what about the oozing fundal varices?
The oozing fundal varices were also not treated. We also clarified this in the text as follows: Repeat endoscopy the next day revealed oozing from fundal and oesophageal varices. The esophageal varices were treated with ligation, and the patient became hemodynamically stable and required no more transfusions..
In addition, first they write that vitamin K antagonists should not be given in combination with aspirin but immediately thereafter, they do it anyway after discussion with the patient and his cardiologist. After the bleeding, propranolol and enoxaparin were initiated. Probably, warfarin and aspirin were stopped but this is not mentioned.
Thank you for spotting this omission, we indeed stopped the patient's aspirin and vitamin K antagonist. This is now added in the text as follows: His aspirin and vitamin K antagonist were discontinued and vitamin K was administered prophylactically to maintain reversal of his oral anticoagulant.
Another, funnier think that also another reviewer did not reflect about, is the gastro-oesophageal suture line of the previous Billroth surgery. Here one obviously mixes Billroth with gastric bypass. The correct term is either gastro-duodenal (Billroth I) or gastro-jejunal (Billroth II) suture line.