Endoscopic and Histopathological Findings of the Esophagus, Stomach, and Duodenum in Patients with Crohn’s Disease from a Reference Center in Bahia, Brazil
, Luiz Antônio Rodrigues de Freitas 2, Rita de Cássia Reis Cruz 3, Isaac Neri de Novais Silva 4, Laíla Damasceno Andrade 5, Paola Nascimento Marques 4, Júlia Cordeiro Braga 4, Flora Maria Lorenzo Fortes 3, Katia Rejane Marques Brito 3, Jaciane Araújo Mota Fontes 3, Neogélia Pereira Almeida 3, Valdiana Cristina Surlo 3, Raquel Rocha 6, André Castro Lyra 1 and Genoile Oliveira Santana 1,4,*
Round 1
Reviewer 1 Report
The subject is very interesting, however:
- the patients group is too small
- there is no control group (without CD) for conlusion
- the clinical symptoms are not well described
- the majority of patients with CD (87,9%) had other diseases from upper gastrointestinal tract? what about patients without CD? Maybe 80-90% of all patients (without CD) had esophageal, stomach or duodenum diseases in your Endoscopic Department?
In my opinion, the results are not convincing, they require further research and comparison with the control group. My decision is: rejection.
Author Response
Review Report: the patients group is too small.
Answer: Accepted request.
Review Report: there is no control group (without CD) for conclusion
Answer: Accepted request.
Review Report: the clinical symptoms are not well described
Answer: We selected a convenience sample in a population of patients with Crohn's disease under follow-up, in order to identify the presence of endoscopic and histopathological findings that could suggest the presence of upper gastrointestinal involvement in these patients. All patients were asked about the presence of gastrointestinal symptoms before the esophagogastroduodenoscopy was performed, including: heartburn, nausea, vomiting, dysphagia, odynophagia, abdominal pain, abdominal distension, postprandial fullness, weight loss; however, we related in results only those that were more frequent. When considering the presence of gastrointestinal symptoms, both symptomatic and asymptomatic patients exhibited a high frequency of endoscopic findings, which were nonspecific, with no difference between groups.
Review Report: the majority of patients with CD (87,9%) had other diseases from upper gastrointestinal tract? what about patients without CD? Maybe 80-90% of all patients (without CD) had esophageal, stomach or duodenum diseases in your Endoscopic Department?
Answer: The frequency of endoscopic findings was 87.9%. The most frequent macroscopic alterations were unspecified as edema, erythema and erosions. No strictures and fistulas, findings that suggest CD, were not identified in the esophagus, stomach and duodenum in this sample. The finding of gastroduodenal erosions alone in patients with negative H. pylori, does not meet the criteria necessary to define the involvement of these segments and the correlation between endoscopic and histopathological findings is important to define the diagnosis of CD in this case. We did not have the frequency of endoscopic findings in a control group for comparison.
Reviewer 2 Report
The manuscript " Endoscopic and histopathological findings of the esophagus, stomach and duodenum in Crohn’s disease patients from a reference center in Bahia-Brazil " is a cross-sectional study in a single center about the endoscopic and histopathological findings in the esophagus, stomach and duodenum in Crohn’s disease patients.
The topic is relatively interesting, the patients’ cohort is small, but authors specified well the shortcomings of their work.
They found an high presence of upper GI involvement in CD patients, in symptomatic patients, but in asymptomatic controls too.
The ECCO guidelines suggest to perform upper GI endoscopy just in paediatric CD patients at diagnosis. Do you suggest to perform it in your population too? Please clarify this aspect in the text.
In particular in the introduction include ECCO guidelines reference to explain when and how to perform upper GI endoscopy in CD patients.
Author Response
Review Report: The manuscript " Endoscopic and histopathological findings of the esophagus, stomach and duodenum in Crohn’s disease patients from a reference center in Bahia-Brazil " is a cross-sectional study in a single center about the endoscopic and histopathological findings in the esophagus, stomach and duodenum in Crohn’s disease patients.
The topic is relatively interesting, the patients’ cohort is small, but authors specified well the shortcomings of their work.
They found a high presence of upper GI involvement in CD patients, in symptomatic patients, but in asymptomatic controls too.
The ECCO guidelines suggest to perform upper GI endoscopy just in paediatric CD patients at diagnosis. Do you suggest to perform it in your population too?
Answer: No. Only one study was done with all the patients with Crohn’s disease included at the moment of diagnosis (Reference number 5, Horje et al). Despite this greater frequency of endoscopic findings when the endoscopy is performed at the moment of diagnosis, as many findings are nonspecific and with uncertain relevance in clinical practice. Additional studies are needed to confirm the benefit of EGD in asymptomatic adult patients at the time of diagnosis.
Review Report: In particular in the introduction include ECCO guidelines reference to explain when and how to perform upper GI endoscopy in CD patients.
Answer: Accepted request. At the moment, we should perform EGD in symptomatic adult patients with CD, unlike for the pediatric population.
Reviewer 3 Report
This MS reports an evaluation of upper gut findings in a group of adults with Crohn disease
SPECIFIC
- The authors refer to rates of upper gut involvement of 5% or less in individuals with CD. The rates in children with CD are at least ten fold higher than this. This should be considered also
- The authors refer to "CD patients". This should be written (in all locations) as "patients with CD"
- The description of this work should use the past tense not the present tense (ABSTRACT)
- 4 should be Four (ABSTRACT)
- The sentence giving the frequency of H. pylori would be best given prior to discussing the relevance of this infection
- It was not clear in the abstract that this was a prevalent cohort (some time after diagnosis). These individuals underwent the endoscopy expressly for this study?
- Did their endoscopic findings reflect the finding present on their diagnostic upper scope at the time of diagnosis of CD? Given this, how do the authors account for the impact of therapeutic intervention upon the rate of findings of CD in the upper gut?
- The authors did not take routine biopsies from the oesophagus. They can not therefore assess the rate of histological changes of CD in this location
- Line 64 has a typo
- Some items (such as alcohol intake) were not defined in the METHODS
- Azathioprine and Methotrexate have been mis-spelled
- The DISCUSSION could be shortened and more focused
- The locations of references needs to be corrected. for example: "Sonnenberg et al. [23]..."
- Some of the references do not appear to be formatted correctly
Author Response
Review Report: 1.The authors refer to rates of upper gut involvement of 5% or less in individuals with CD. The rates in children with CD are at least ten fold higher than this. This should be considered also
Answer: accepted request.
Review Report: 2.The authors refer to "CD patients". This should be written (in all locations) as "patients with CD" -
Answer: accepted request.
Review Report: 3.The description of this work should use the past tense not the present tense (ABSTRACT)
Answer: accepted request.
Review Report: 4. 4 should be Four (ABSTRACT)
Answer: accepted request.
Review Report: 5.The sentence giving the frequency of H. pylori would be best given prior to discussing the relevance of this infection
Answer: accepted request.
Review Report: 6.It was not clear in the abstract that this was a prevalent cohort (some time after diagnosis). These individuals underwent the endoscopy expressly for this study?
Answer: Yes.
Review Report: 7. Did their endoscopic findings reflect the finding present on their diagnostic upper scope at the time of diagnosis of CD? Given this, how do the author's account for the impact of therapeutic intervention upon the rate of findings of CD in the upper gut?
Answer: No, because we used a sample of patients being followed up at the outpatient clinic, the majority of them were being treated with immunosuppressants or biological therapy, so we believe that this factor contributed to not having identified more specific findings, such as epithelioid granuloma.
Review Report: 8. The authors did not take routine biopsies from the oesophagus. They can not therefore assess the rate of histological changes of CD in this location.
Answer: In adult patients, unlike the pediatric population, esophageal biopsies are not recommended in the absence of visible lesions during endoscopy. Esophageal biopsies were done in all patients with visible lesions.
Review Report: 9. Line 64 has a typo
Answer: accepted request.
Review Report: 10. Some items (such as alcohol intake) were not defined in the METHODS
Answer: accepted request.
Review Report: 11. Azathioprine and Methotrexate have been mis-spelled
Answer: accepted request.
Review Report: 12. The DISCUSSION could be shortened and more focused
Answer: accepted request.
Review Report: 13.The locations of references needs to be corrected. for example: "Sonnenberg et al. [23]..."
Answer: accepted request.
Review Report: 14. Some of the references do not appear to be formatted correctly
Answer: accepted request.
Reviewer 4 Report
The absence of a healthy and/or a disease control group represents the major weakness of the study. For examble the prevalence of H. pylori infection in patients with IBD is lower as compared with the healthy population. This could also be a reality in Brazil. However such a useful conclusion is impossible to be derived from the paper.
Author Response
Review Report: The absence of a healthy and/or a disease control group represents the major weakness of the study. For example the prevalence of H. pylori infection in patients with IBD is lower as compared with the healthy population. This could also be a reality in Brazil. However such a useful conclusion is impossible to be derived from the paper.
Answer: accepted request. We understand that the absence of a control group represents the major weakness of the study and we address this aspect in the discussion.
Round 2
Reviewer 1 Report
The group of patients is still too small for conlusion and there is no control group, my decision is: rejection.
Author Response
On behalf of my co-authors, thank you for the review and guidance.
Reviewer 3 Report
Thank you for your revisions, that have improved the MS
1. The term "IBD patients" remains and must also be corrected.
2. The placement of references remains incorrect (when using an author name and et al, the reference number must follow the et al, and not be somewhat distant from that)
3. There remain grammatical errors and related errors that should also be corrected
Author Response
Reviewer's request: 1. The term "IBD patients" remains and must also be corrected.
Answer: Accepted request.
Reviewer's request: 2. The placement of references remains incorrect (when using an author name and et al, the reference number must follow the et al, and not be somewhat distant from that)
Answer: Accepted request. The references have been corrected.
Reviewer's request: 3. There remain grammatical errors and related errors that should also be corrected
Answer: Accepted request. The article was revised by the MDPI English Editing as suggested
Reviewer 4 Report
No further comments
Author Response
On behalf of my co-authors, thank you for the review and guidance.
