Reviewer's report 
 Partially Responsive Celiac Disease Resulting from Small Intestinal Bacterial Overgrowth and Title: 
Lactose Intolerance 
 2  4 February 2004 Version: Date: 
 Antonio Tursi Reviewer: 
Reviewer's report: 
General issues: 
Ghoshal et al. reported two cases of celiac disease patients partially responsive to gluten-free diet (GFD) and affected by small intestinal bacterial overgrowth (SIBO) (one patient) and lactose intolerance (the other one patient). They concluded that in celiac partially or unresponsive to GFD 
SIBO or lactose intolerance should be suspected. 
Although this last statement is condivisibile, we should not never forget the risk of refractory celiac 
disease before to look for other causes of unresponsiveness to GFD. 
Specific comments: 
The authors should describe better the duodenal histology of the studied patient according to 
modified Marsh classification (Oberhuber G, Grandisch G, Vogelsang H. The histopathology of 
coeliac disease: time for a standardized report scheme for pathologists. Eur J Gastroenterol Hepatol
1999;11: 1185-94). 
How many months the first patient was on GFD before to define the duodenal histology “normal”? 
Did the authors evaluated anti-gliadin and/or anti-tissue transglutaminase antibodies? 
What methods have been used to perform anti-endomysium evaluation? 
The paragraph Discussion should be improved. 
1. The authors stated that “Lactose intolerance could be another cause for such inadequate response to GFD. Whether this is primary or secondary lactose intolerance is matter of 
conjecture…….” . But what is the authors’ opinion about this matter? 
2. None reference is described about the risk of refractory celiac disease in poor or unresponsive celiac patient to GFD. The authors should debate also this point. 3. Finally, the authors should explain better why SIBO or lactose intolerance may perpetuate the 
symptoms in these patients. 
 Accept after minor essential revisions What next?: 
 An article whose findings are important to those with closely related research Level of interest: 
interests 
 Needs some language corrections before being published Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
None 
Reviewer's report 
 Partially Responsive Celiac Disease Resulting from Small Intestinal Bacterial Overgrowth and Title: 
Lactose Intolerance 
 2  4 February 2004 Version: Date: 
 Antonio Tursi Reviewer: 
Reviewer's report: 
General issues: 
Ghoshal et al. reported two cases of celiac disease patients partially responsive to gluten-free diet (GFD) and affected by small intestinal bacterial overgrowth (SIBO) (one patient) and lactose intolerance (the other one patient). They concluded that in celiac partially or unresponsive to GFD 
SIBO or lactose intolerance should be suspected. 
Although this last statement is condivisibile, we should not never forget the risk of refractory celiac 
disease before to look for other causes of unresponsiveness to GFD. 
Specific comments: 
The authors should describe better the duodenal histology of the studied patient according to 
modified Marsh classification (Oberhuber G, Grandisch G, Vogelsang H. The histopathology of 
coeliac disease: time for a standardized report scheme for pathologists. Eur J Gastroenterol Hepatol
1999;11: 1185-94). 
How many months the first patient was on GFD before to define the duodenal histology “normal”? 
Did the authors evaluated anti-gliadin and/or anti-tissue transglutaminase antibodies? 
What methods have been used to perform anti-endomysium evaluation? 
The paragraph Discussion should be improved. 
1. The authors stated that “Lactose intolerance could be another cause for such inadequate response to GFD. Whether this is primary or secondary lactose intolerance is matter of 
conjecture…….” . But what is the authors’ opinion about this matter? 
2. None reference is described about the risk of refractory celiac disease in poor or unresponsive celiac patient to GFD. The authors should debate also this point. 3. Finally, the authors should explain better why SIBO or lactose intolerance may perpetuate the 
symptoms in these patients. 
 Accept after minor essential revisions What next?: 
 An article whose findings are important to those with closely related research Level of interest: 
interests 
 Needs some language corrections before being published Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
None 
Please review this paper.
user
Reviewer's report 
 Partially Responsive Celiac Disease Resulting from Small Intestinal Bacterial Overgrowth and Title: 
Lactose Intolerance 
 2  4 February 2004 Version: Date: 
 Antonio Tursi Reviewer: 
Reviewer's report: 
General issues: 
Ghoshal et al. reported two cases of celiac disease patients partially responsive to gluten-free diet (GFD) and affected by small intestinal bacterial overgrowth (SIBO) (one patient) and lactose intolerance (the other one patient). They concluded that in celiac partially or unresponsive to GFD 
SIBO or lactose intolerance should be suspected. 
Although this last statement is condivisibile, we should not never forget the risk of refractory celiac 
disease before to look for other causes of unresponsiveness to GFD. 
Specific comments: 
The authors should describe better the duodenal histology of the studied patient according to 
modified Marsh classification (Oberhuber G, Grandisch G, Vogelsang H. The histopathology of 
coeliac disease: time for a standardized report scheme for pathologists. Eur J Gastroenterol Hepatol
1999;11: 1185-94). 
How many months the first patient was on GFD before to define the duodenal histology “normal”? 
Did the authors evaluated anti-gliadin and/or anti-tissue transglutaminase antibodies? 
What methods have been used to perform anti-endomysium evaluation? 
The paragraph Discussion should be improved. 
1. The authors stated that “Lactose intolerance could be another cause for such inadequate response to GFD. Whether this is primary or secondary lactose intolerance is matter of 
conjecture…….” . But what is the authors’ opinion about this matter? 
2. None reference is described about the risk of refractory celiac disease in poor or unresponsive celiac patient to GFD. The authors should debate also this point. 3. Finally, the authors should explain better why SIBO or lactose intolerance may perpetuate the 
symptoms in these patients. 
 Accept after minor essential revisions What next?: 
 An article whose findings are important to those with closely related research Level of interest: 
interests 
 Needs some language corrections before being published Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
None 
assistant