Clinical and Endoscopic Features of Upper Gastrointestinal Bleeding Associated with Helicobacter pylori Infection: A Retrospective Cohort Study in the Colombian Caribbean (2021–2023)

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This paper reports a retrospective cohort study from Colombia on patients with upper gastrointestinal bleeding (UGIB) associated with Helicobacter pylori. It describes incidence, clinical features, comorbidities, endoscopic findings, and outcomes. The dataset covers 329 cases over a two-year period, with 44 patients confirmed as H. pylori positive. The work is relevant because regional data on this topic are limited, and the study provides descriptive information on clinical and endoscopic patterns in this population.

1. The methods section would benefit from more detail on how missing data were handled. Please clarify whether endoscopic examinations were performed by the same group of endoscopists or varied across operators, since inter-observer variability can affect Forrest classification. Statistical methods are described, but it is not clear if adjustments for multiple comparisons were considered.
2. The discussion should place more emphasis on why the prevalence of H. pylori in UGIB was only 13% in this cohort, which seems lower than reported regional infection rates. Possible explanations (e.g., prior eradication therapy, diagnostic method sensitivity, or patient selection) should be discussed. The link between hypertension and male predominance is interesting but underdeveloped. It would help to expand how vascular comorbidity may interact with bleeding risk.
3. Mortality and complication rates are reported, but confidence intervals are not provided. These would give readers a better sense of precision. In Table 3, comorbidities and pathology could be grouped more clearly to avoid repetition.
4. The introduction cites global and regional studies but would benefit from a clearer explanation of why this local cohort adds new insights. In Figure 1 and Figure 2, please ensure legends are fully self-explanatory for international readers. Some abbreviations (e.g., “UGI” for ulcer) should be defined consistently at first use. Typographical issues: for example, “UGI” might be better written as “GI ulcer” or “gastroduodenal ulcer” for clarity.

Author Response

Thank you very much for taking the time to review our manuscript entitled “Clinical and Endoscopic Features of Upper Gastrointestinal Bleeding Associated with Helicobacter pylori Infection: A Retrospective Cohort Study in the Colombian Caribbean (2021–2023).” We sincerely appreciate your thoughtful and constructive comments. Please find below our detailed responses to each point raised. All corresponding revisions and corrections have been carefully incorporated into the revised version of the manuscript and are clearly highlighted in the resubmitted files. 

Comments 1: The methods section would benefit from more detail on how missing data were handled. Please clarify whether endoscopic examinations were performed by the same group of endoscopists or varied across operators, since inter-observer variability can affect Forrest classification. Statistical methods are described, but it is not clear if adjustments for multiple comparisons were considered.
Response 1: We thank the reviewer for this important observation. The Methods section has been expanded to clarify all three issues:

• Missing data: We now specify that missing data represented <5% of the dataset, that affected cases were excluded using a complete-case approach, and that no imputation was applied.
• Endoscopists and inter-observer variability: The manuscript now states that all procedures were performed by a stable group of three board-certified gastroenterologists following a standardized institutional protocol, with periodic calibration meetings to ensure consistency in Forrest classification.
• Multiple comparisons: We added that secondary analyses were adjusted using the Holm–Bonferroni method to control the type I error rate.

These additions strengthen methodological transparency and rigor. 

 
Comments 2: The discussion should place more emphasis on why the prevalence of H. pylori in UGIB was only 13% in this cohort, which seems lower than reported regional infection rates. Possible explanations (e.g., prior eradication therapy, diagnostic method sensitivity, or patient selection) should be discussed. The link between hypertension and male predominance is interesting but underdeveloped
Response 2: We appreciate this thoughtful comment. The Discussion section has been expanded to better contextualize the 13% prevalence of H. pylori, explaining that:

• prior eradication therapy,
• reduced sensitivity of histology and rapid urease tests when patients are on PPIs or antibiotics, and
• selection patterns within a tertiary referral center

may all contribute to a lower observed prevalence compared with community or population-based studies. Additionally, we strengthened the explanation of the association between hypertension and male predominance, integrating literature on vascular dysfunction, endothelial fragility, and the impact of antiplatelet therapy on bleeding risk in older hypertensive males.

Comments 3: It would help to expand how vascular comorbidity may interact with bleeding risk. Mortality and complication rates are reported, but confidence intervals are not provided. In Table 3, comorbidities and pathology could be grouped more clearly to avoid repetition
Response 3: We thank the reviewer for this relevant suggestion. In response:

• We expanded the Discussion with a dedicated explanation of how hypertension and other vascular comorbidities may increase susceptibility to mucosal injury and impair hemostasis, thereby influencing UGIB severity.
• Confidence intervals (95% CIs) were reviewed and added in all cases where pertinent and effect estimates in the Statistical Analysis section.
• Table 3 was reorganized into three structured blocks—Comorbidities, Pathological Findings, and Complications—to improve clarity and avoid redundancy, as recommended.

Comments 4: The introduction cites global and regional studies but would benefit from a clearer explanation of why this local cohort adds new insights. In Figure 1 and Figure 2, please ensure legends are fully self-explanatory for international readers. Some abbreviations (e.g., ‘UGI’ for ulcer) should be defined consistently at first use. Typographical issues: for example, ‘UGI’ might be better written as ‘GI ulcer’ or ‘gastroduodenal ulcer’ for clarity.

Response 2: We appreciate these constructive comments. Revisions include:

• The Introduction now explicitly emphasizes how this regional cohort contributes novel insights by representing an understudied population in the Colombian Caribbean, characterized by unique epidemiological, socioeconomic, and comorbidity patterns.
• Figure legends have been rewritten to be fully self-explanatory and accessible to international readers.
• All abbreviations have been standardized and defined at first use.
• The term “UGI” has been replaced systematically with “GI ulcer” or “gastroduodenal ulcer” for consistency and clarity, as advised. 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The article "Clinical and Endoscopic Features of Upper Gastrointestinal Bleeding Associated with Helicobacter pylori Infection: A Retrospective Cohort Study in the Colombian Caribbean (2021–2023)" is a retrospective cohort study provides an integrative overview of the clinical, pathological, and endoscopic features of upper gastrointestinal bleeding (UGIB)associated with H. pylori infection in a tertiary referral center in the Colombian Caribbean. The findings reaffirm the clinical significance of H. pylori as a persistent etiological agent of gastroduodenal bleeding, even in a setting with improved eradication programs and endoscopic management protocols. This article validates the known finding in new cohort of population.

It is a well-studied and well-written manuscript. However, suggestion for improvement of the manuscript is as follow:

1. Please add limitations of the study at the end of the discussion. Conclusion can be made concise. Please thoroughly proofread and edit the manuscript to eliminate redundancy and improve clarity and flow. Repetitive sentences and overlapping information should be revised/removed to enhance readability and ensure a more concise and cohesive narrative throughout the article.

Author Response

Comment (General): The article provides an integrative overview of the clinical, pathological, and endoscopic features of UGIB associated with H. pylori. The findings reaffirm the clinical significance of H. pylori… It is a well-studied and well-written manuscript.
Response (General): We thank the reviewer for the encouraging assessment and appreciation of the scientific value of our study.

 
Comments 1: Please add limitations of the study at the end of the discussion
Response 1: We appreciate this important suggestion. A dedicated Limitations paragraph has been added at the end of the Discussion. This section now discusses the retrospective design, the potential underestimation of H. pylori prevalence due to diagnostic sensitivity during PPI/antibiotic exposure, and the possibility of residual confounding. These additions strengthen the interpretability and transparency of the findings.

 
Comments 2: Conclusion can be made concise
Response 2: Thank you for this observation. The Conclusion section has been rewritten to be more concise and focused. Redundant phrases were removed, and the remaining text clearly summarizes the main findings and their clinical implications in a streamlined manner.

 
Comments 3: Please thoroughly proofread and edit the manuscript to eliminate redundancy and improve clarity and flow.
Response 3: We appreciate this helpful recommendation. The manuscript was thoroughly proofread, and clarifications were applied throughout to remove repetitive statements, streamline transitions, and improve the narrative flow of the Introduction, Results, and Discussion. Stylistic and linguistic refinements were also incorporated to enhance readability. 

 
Comments 4: Repetitive sentences and overlapping information should be revised/removed to enhance readability and ensure a more concise and cohesive narrative throughout the article.
Response 4: Thank you for highlighting this point. We revised several sections—particularly the Introduction and Discussion—to remove overlapping descriptions of clinical patterns and endoscopic findings. Duplicated concepts were consolidated, and each subsection was refined to ensure a cohesive and non-redundant narrative.

Author Response File: Author Response.pdf