Non-Cirrhotic Ascites: Causes and Management

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This manuscript did not bring any new knowledge or understanding.

Author Response

Reviewer # 1.

 

This manuscript did not bring any new knowledge or understanding.

 

 

Response. We thank Reviewer #1 for this feedback. However, as this is a review article, the primary goal is to provide a comprehensive synthesis of existing literature. It is worth mentioning that our previous article on this topic (in French, published more than 10 years ago) was one of the most downloaded after publication, highlighting continued interest in this subject.

 

 

 

Reviewer 2 Report

Comments and Suggestions for Authors

In this review, the authors provided useful information about the various causes of ascites.
Remarks:
1. Revise the title of the manuscript. Indeed, there is a lot of information about cirrhotic ascites in the text.
2. Clearly state the purpose of the publication.
3. Revise the "Introduction" section, which deals only with cirrhotic ascites, which does not correspond to the stated topic of the manuscript.
4. Section 2. How to Evaluate Ascites.
Please note that in addition to the analysis of ascitic fluid after diagnostic paracentesis and radiology diagnostics, the initial assessment of ascites should include medical history, physical examination, blood tests. This information needs to be added.
5. Subsection 3.1. Portal Hypertension.
Please familiarize the classification of portal hypertension (for example, https://doi.org/10.5009/gnl230072) and make appropriate corrections in the text and Table 3.
6. Explain Section 3.4. Others.
Both acute and chronic liver failure may be accompanied by ascites. Write about it in more detail.
7. It is sufficient to describe the causes, diagnosis and management of ascites in various diseases in the relevant sections of the manuscript and there is no need to separate Section 4. Management.
8. It is necessary to revise the rubrication of the manuscript text. For example, subsections: 3.5.3. Urinary Tract, 3.5.4. Malnutrition, 3.5.5. Radiotherapy, 3.5.6. Thyroid, 3.5.7. Kidney, does not apply to Section 3.5. Gynecologic Causes.
9. Revise Table 1. It is not informative.

Author Response

Reviewer # 2.

 

In this review, the authors provided useful information about the various causes of ascites.

Remarks:
Comment 1. Revise the title of the manuscript. Indeed, there is a lot of information about cirrhotic ascites in the text.

 

Response 1. We appreciate this suggestion. The title has been revised accordingly to better reflect the content of the manuscript.

 

Comment 2. Clearly state the purpose of the publication.

 

Response 2. We agree with the reviewer and have added a specific sentence at the end of the introduction to clearly state the purpose of this review.

 

 

Comment 3. Revise the "Introduction" section, which deals only with cirrhotic ascites, which does not correspond to the stated topic of the manuscript.

 

Response 3. The Introduction section has been revised to expand the context beyond cirrhotic ascites and better align with the broader topic of the manuscript.

 

Comment 4. Section 2. How to Evaluate Ascites.

Please note that in addition to the analysis of ascitic fluid after diagnostic paracentesis and radiology diagnostics, the initial assessment of ascites should include medical history, physical examination, blood tests. This information needs to be added.

 

Response 4. Thank you for this important comment. We have added a sentence to the introduction of this section to include the initial clinical assessment of ascites, as suggested.

 

Comment 5. Subsection 3.1. Portal Hypertension.

Please familiarize the classification of portal hypertension (for example, https://doi.org/10.5009/gnl230072) and make appropriate corrections in the text and Table 3.

 

Response 5. We appreciate this reference and have made the appropriate updates to both the text and Table 3 to reflect the suggested classification of portal hypertension. We have added also the reference.

Comment 6. Explain Section 3.4. Others.

Both acute and chronic liver failure may be accompanied by ascites. Write about it in more detail.

 

Response 6. We agree with the reviewer and have expanded this section to include more detailed information about ascites in the context of both acute and chronic liver failure.

 

Comment 7. It is sufficient to describe the causes, diagnosis and management of ascites in various diseases in the relevant sections of the manuscript and there is no need to separate Section 4. Management.

 

Response 7. Thank you for your suggestion. We intended to provide a simplified approach for clinicians, but we have now integrated the management section directly into the relevant disease sections. If this structure still appears unnecessary after these revisions, please let us know.

 

Comment 8. It is necessary to revise the rubrication of the manuscript text. For example, subsections: 3.5.3. Urinary Tract, 3.5.4. Malnutrition, 3.5.5. Radiotherapy, 3.5.6. Thyroid, 3.5.7. Kidney, does not apply to Section 3.5. Gynecologic Causes.

 

Response 8. We agree with the reviewer and have corrected the rubrication to place these subsections under more appropriate categories.

 

Comment 9. Revise Table 1. It is not informative.

 

Response 9. We thank the reviewer for this remark. We have revised Table 1 to include an explanation, making it more informative and aligned with the manuscript’s objectives.

 

 

Reviewer 3 Report

Comments and Suggestions for Authors

The article is an excellent review of ascites, which is a frequent complication of liver cirrhosis, heart or kidney failure, or systemic diseases such as infections, neoplasias, and other less frequent entities.

Each of the pathophysiological mechanisms is adequately defined and analyzed

The study of the ascites fluid obtained by paracentesis and the determination of the albumin concentration gradient continue to be the gold standard to establish its etiology, however in those cases in which there is no cirrhosis, histological and microbiological studies must be performed and the elements that compose it must be determined

In the work they mention that the high cholesterol concentration in the ascites fluid in their experience is very useful in patients with malignant neoplasias that infiltrate the peritoneal serosa, however, I consider that it should be taken with caution since a greater number of studies are required to establish its sensitivity, specificity, and positive predictive value.

The presentation of the tables seems adequate to me, and the wording is acceptable.

The topic is comprehensively reviewed based on a systematic review of the best scientific evidence published in the literature

It may be accepted for publication.

Comments on the Quality of English Language

It´s OK

Author Response

Reviewer # 3.

 

The article is an excellent review of ascites, which is a frequent complication of liver cirrhosis, heart or kidney failure, or systemic diseases such as infections, neoplasias, and other less frequent entities.

Each of the pathophysiological mechanisms is adequately defined and analyzed

The study of the ascites fluid obtained by paracentesis and the determination of the albumin concentration gradient continue to be the gold standard to establish its etiology, however in those cases in which there is no cirrhosis, histological and microbiological studies must be performed and the elements that compose it must be determined

In the work they mention that the high cholesterol concentration in the ascites fluid in their experience is very useful in patients with malignant neoplasias that infiltrate the peritoneal serosa, however, I consider that it should be taken with caution since a greater number of studies are required to establish its sensitivity, specificity, and positive predictive value.

The presentation of the tables seems adequate to me, and the wording is acceptable.

The topic is comprehensively reviewed based on a systematic review of the best scientific evidence published in the literature

It may be accepted for publication.

 

Response: We thank the reviewer for the nice and valuable advice. We add a specific commentary concerning cholesterol concentration.

 

 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Sometimes the diagnosis of the cause of ascites can be challenging, and exploratory laparotomy is the final step.

Author Response

Reviewer 1.

Comment: Sometimes the diagnosis of the cause of ascites can be challenging, and exploratory laparotomy is the final step.

Response: We thank the reviewer for this valuable comment. We underline it in the text.

Reviewer 2 Report

Comments and Suggestions for Authors

It is more logical to make the subsection "3.2.5. Others" the last one, i.e. 3.2.6.
I think that the section "4. Management" is not needed.

Author Response

Comment 1. It is more logical to make the subsection "3.2.5. Others" the last one, i.e. 3.2.6.

Response 1. We thank the reviewer for the remark. We changed subsections.

 

Comment 2. I think that the section "4. Management" is not needed.

Response 2. Thank you for the comment. We retrieved the section 4.