Reviewer ’s report  
 
Title : Intestinal fistula accompanied by recurrent peritonitis associa ted with peritoneal dial ysis: a 
case report  
 
Version: 0 Date: 02 Feb 2020  
 
Reviewer: Joyita Bharati  
 
Reviewer's report:  
 
Please include all comments for the authors in this box rather than uploading your report as an 
attachment. Please only upload as attachments annotated versions of manuscripts, g raphs, 
supporting materials or other aspects of your report which cannot be included in a text format.  
 
Please overwrite this text when adding your comments to the authors.  
 
This case reports highlights an important information on rare complications of peri toneal dialysis 
(PD) and a successful conservative management of the same. Despite the patient having acute 
peritonitis with intestinal fistula, catheter removal (without surgical repair) was successful in the 
management, which is interesting. Following ar e few comments and queries on this manuscript.  
 
No.1: Line #23 states that "some complications are common such as peritonitis, pain and 
feculent dialysate effluent with watery diarrhoea" with a reference [1]. This statement is not 
entirely correct as fecule nt dialysate effluent is a rare complication of PD related to bowel 
perforation by the catheter. The reference [Wang R, Chen Z, Wang J, Zhang X, Shou Z, Chen J. 
Delayed bowel perforation in a peritoneal dialysis patient: a case report and literature review . 
Perit Dial Int. 2014;34:460 -6] does not state this either.  
 
No.2: Line #31 -32 state that "leakage of peritoneal dialysis fluid was noted at the orifice of the 
peritoneal dialysis tube". Further evaluation of this finding was not mentioned in the followin g 
section.  
 
No.3: Lines #62 -64 state that "Perforation may also occur in association with chronic peritoneal 
dialysis, with its repeated episodes of peritonitis.." Repeated peritonitis is typically a 
manifestation rather than cause of intestinal perforation/fistula fo llowing PD catheter insertion. 
So, the assumption that repeated peritonitis caused intestinal perforation/fistula in this patient 
may not be correct. Peritoneal adhesion (between intestine and abdominal wall) following 
peritonitis may predispose for bowel wall perforation. The presence of extensive peritoneal 
calcification (as described in this patient) could be attributed to cause intestinal 
perforation/fistula in the index case. A search or note on colonic diverticulitis in this patient 
(which is a known risk factor to cause intestinal perforation/fistula) would be worthwhile. 
Moreover, previous history of intermittent cessation of PD due to repeated peritonitis, if present 
in this patient, could have caused this complication as an immobile catheter withou t fluid in the 
abdomen predisposes to this complication. Presence of dialysate leak around the orifice of PD 
catheter could imply increase in abdominal pressure. Increased abdominal pressure, in turn, is 
associated with intestinal perforation, as seen in p atients with polycystic kidney disease.  
 
No. 4: Figures should preferably have arrows/arrowheads to mark the findings  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Unable to assess  
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of co mpeting interests, considering the following questions:  
 
1.  Have you in the past five years received reimbursements, f ees, funding, or salary 
from an organisation that may in any way gain or lose financial ly from the 
publication of this manuscript, either n ow or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat may in any way gain or 
lose financially from the publication of this manuscript, either now or in the 
future?  
 
3.  Do you hold or are you currently applying for any patents rela ting to the content 
of the manuscript?  
 
4.  Have you received reimbursements, fees, funding, or salary from an organization 
that holds or has applied for patents relating to the content of the manuscript?  
 
5.  Do you have any other financial competing interest s? 
 
6.  Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have  no competing in terests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any att achments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title : Intestinal fistula accompanied by recurrent peritonitis associa ted with peritoneal dial ysis: a 
case report  
 
Version: 0 Date: 02 Feb 2020  
 
Reviewer: Joyita Bharati  
 
Reviewer's report:  
 
Please include all comments for the authors in this box rather than uploading your report as an 
attachment. Please only upload as attachments annotated versions of manuscripts, g raphs, 
supporting materials or other aspects of your report which cannot be included in a text format.  
 
Please overwrite this text when adding your comments to the authors.  
 
This case reports highlights an important information on rare complications of peri toneal dialysis 
(PD) and a successful conservative management of the same. Despite the patient having acute 
peritonitis with intestinal fistula, catheter removal (without surgical repair) was successful in the 
management, which is interesting. Following ar e few comments and queries on this manuscript.  
 
No.1: Line #23 states that "some complications are common such as peritonitis, pain and 
feculent dialysate effluent with watery diarrhoea" with a reference [1]. This statement is not 
entirely correct as fecule nt dialysate effluent is a rare complication of PD related to bowel 
perforation by the catheter. The reference [Wang R, Chen Z, Wang J, Zhang X, Shou Z, Chen J. 
Delayed bowel perforation in a peritoneal dialysis patient: a case report and literature review . 
Perit Dial Int. 2014;34:460 -6] does not state this either.  
 
No.2: Line #31 -32 state that "leakage of peritoneal dialysis fluid was noted at the orifice of the 
peritoneal dialysis tube". Further evaluation of this finding was not mentioned in the followin g 
section.  
 
No.3: Lines #62 -64 state that "Perforation may also occur in association with chronic peritoneal 
dialysis, with its repeated episodes of peritonitis.." Repeated peritonitis is typically a 
manifestation rather than cause of intestinal perforation/fistula fo llowing PD catheter insertion. 
So, the assumption that repeated peritonitis caused intestinal perforation/fistula in this patient 
may not be correct. Peritoneal adhesion (between intestine and abdominal wall) following 
peritonitis may predispose for bowel wall perforation. The presence of extensive peritoneal 
calcification (as described in this patient) could be attributed to cause intestinal 
perforation/fistula in the index case. A search or note on colonic diverticulitis in this patient 
(which is a known risk factor to cause intestinal perforation/fistula) would be worthwhile. 
Moreover, previous history of intermittent cessation of PD due to repeated peritonitis, if present 
in this patient, could have caused this complication as an immobile catheter withou t fluid in the 
abdomen predisposes to this complication. Presence of dialysate leak around the orifice of PD 
catheter could imply increase in abdominal pressure. Increased abdominal pressure, in turn, is 
associated with intestinal perforation, as seen in p atients with polycystic kidney disease.  
 
No. 4: Figures should preferably have arrows/arrowheads to mark the findings  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Unable to assess  
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of co mpeting interests, considering the following questions:  
 
1.  Have you in the past five years received reimbursements, f ees, funding, or salary 
from an organisation that may in any way gain or lose financial ly from the 
publication of this manuscript, either n ow or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat may in any way gain or 
lose financially from the publication of this manuscript, either now or in the 
future?  
 
3.  Do you hold or are you currently applying for any patents rela ting to the content 
of the manuscript?  
 
4.  Have you received reimbursements, fees, funding, or salary from an organization 
that holds or has applied for patents relating to the content of the manuscript?  
 
5.  Do you have any other financial competing interest s? 
 
6.  Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have  no competing in terests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any att achments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Please review this paper.
user
Reviewer ’s report  
 
Title : Intestinal fistula accompanied by recurrent peritonitis associa ted with peritoneal dial ysis: a 
case report  
 
Version: 0 Date: 02 Feb 2020  
 
Reviewer: Joyita Bharati  
 
Reviewer's report:  
 
Please include all comments for the authors in this box rather than uploading your report as an 
attachment. Please only upload as attachments annotated versions of manuscripts, g raphs, 
supporting materials or other aspects of your report which cannot be included in a text format.  
 
Please overwrite this text when adding your comments to the authors.  
 
This case reports highlights an important information on rare complications of peri toneal dialysis 
(PD) and a successful conservative management of the same. Despite the patient having acute 
peritonitis with intestinal fistula, catheter removal (without surgical repair) was successful in the 
management, which is interesting. Following ar e few comments and queries on this manuscript.  
 
No.1: Line #23 states that "some complications are common such as peritonitis, pain and 
feculent dialysate effluent with watery diarrhoea" with a reference [1]. This statement is not 
entirely correct as fecule nt dialysate effluent is a rare complication of PD related to bowel 
perforation by the catheter. The reference [Wang R, Chen Z, Wang J, Zhang X, Shou Z, Chen J. 
Delayed bowel perforation in a peritoneal dialysis patient: a case report and literature review . 
Perit Dial Int. 2014;34:460 -6] does not state this either.  
 
No.2: Line #31 -32 state that "leakage of peritoneal dialysis fluid was noted at the orifice of the 
peritoneal dialysis tube". Further evaluation of this finding was not mentioned in the followin g 
section.  
 
No.3: Lines #62 -64 state that "Perforation may also occur in association with chronic peritoneal 
dialysis, with its repeated episodes of peritonitis.." Repeated peritonitis is typically a 
manifestation rather than cause of intestinal perforation/fistula fo llowing PD catheter insertion. 
So, the assumption that repeated peritonitis caused intestinal perforation/fistula in this patient 
may not be correct. Peritoneal adhesion (between intestine and abdominal wall) following 
peritonitis may predispose for bowel wall perforation. The presence of extensive peritoneal 
calcification (as described in this patient) could be attributed to cause intestinal 
perforation/fistula in the index case. A search or note on colonic diverticulitis in this patient 
(which is a known risk factor to cause intestinal perforation/fistula) would be worthwhile. 
Moreover, previous history of intermittent cessation of PD due to repeated peritonitis, if present 
in this patient, could have caused this complication as an immobile catheter withou t fluid in the 
abdomen predisposes to this complication. Presence of dialysate leak around the orifice of PD 
catheter could imply increase in abdominal pressure. Increased abdominal pressure, in turn, is 
associated with intestinal perforation, as seen in p atients with polycystic kidney disease.  
 
No. 4: Figures should preferably have arrows/arrowheads to mark the findings  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Unable to assess  
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of co mpeting interests, considering the following questions:  
 
1.  Have you in the past five years received reimbursements, f ees, funding, or salary 
from an organisation that may in any way gain or lose financial ly from the 
publication of this manuscript, either n ow or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat may in any way gain or 
lose financially from the publication of this manuscript, either now or in the 
future?  
 
3.  Do you hold or are you currently applying for any patents rela ting to the content 
of the manuscript?  
 
4.  Have you received reimbursements, fees, funding, or salary from an organization 
that holds or has applied for patents relating to the content of the manuscript?  
 
5.  Do you have any other financial competing interest s? 
 
6.  Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have  no competing in terests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any att achments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant