Reviewer's report 
 Development of bile duct bezoar after cholecystectomy caused by choledochoduodenal fistula Title: 
formation: case report 
 1  10 August 2005 Version: Date: 
 Tony C Tham Reviewer: 
Reviewer's report: 
General 
The authors describe a case of a patient found to have a biliary bezoar thought to be caused by a choledochoduodenal fistula. ------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can 
be reached) 
(1) It is not clear what caused the fistula: could it have been a surgical fistula (choledochoduodenostomy) created at the time of her cholecystectomy 6 years ago? If this was 
surgically created, the authors could be describing the sump syndrome which is a well recognised 
complication of a choledochoduodenostomy. The authors need to be clear on this point because if they assume that this was a spontaneous fistula, they have to explain what caused it. 
(2) The authors should include the ERCP pictures. Were the filling defects in the distal part of the 
duct, ie distal to the fistula? If so, this would support the diagnosis of a sump syndrome. Why was 
the fistula not seen at ERCP? It seems surprising that such a large fistula could have been missed. If 
it was not seen at ERCP, it could be argued that the fistula could have been created iatrogenically at 
the time of her recent surgery. 
(3) The authors have not discussed a few relevant case series and reports (HPB surgery 1993 and 
Foreign material as a cause of choledocholithiasis, Endoscopy 1999). They should discuss these 
papers. (4) The authors main recommendation is that there should be greater awareness of biliary bezoars 
in the setting of a choledochoduodenal fistula at the time of ERCP so that more intensive efforts are 
made to clear the duct endoscopically. How can the endoscopist tell at the time of ERCP whether 
they are bezoars or stones? ------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the 
author can be trusted to correct) (1) The authors keep using the word "stones" from the bile duct when in fact they were actually bezoars. This is confusing and should be clarified. 
(2) There are a few grammatical mistakes throughout the text, eg 2nd paragraph, page 2 "We report 
a recent experience with obstructive jaundice following a bezoar development ....". The grammar 
needs to be checked and corrected. (3)Page 3, paragraph 3 - "scout films": did the authors not mean cholangiogram? 
(4)The authors need to give more details of the ERCP. Was a sphincterotomy performed? Why 
could the stones not be removed? Did they attempt lithotripsy? In many cases, surprisingly large stones can be removed following lithotripsy. 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
 Unable to decide on acceptance or rejection until the authors have responded to the What next?: 
major compulsory revisions 
 An article of limited interest Level of interest: 
 Needs some language corrections before being published Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests. 
Reviewer's report 
 Development of bile duct bezoar after cholecystectomy caused by choledochoduodenal fistula Title: 
formation: case report 
 1  10 August 2005 Version: Date: 
 Tony C Tham Reviewer: 
Reviewer's report: 
General 
The authors describe a case of a patient found to have a biliary bezoar thought to be caused by a choledochoduodenal fistula. ------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can 
be reached) 
(1) It is not clear what caused the fistula: could it have been a surgical fistula (choledochoduodenostomy) created at the time of her cholecystectomy 6 years ago? If this was 
surgically created, the authors could be describing the sump syndrome which is a well recognised 
complication of a choledochoduodenostomy. The authors need to be clear on this point because if they assume that this was a spontaneous fistula, they have to explain what caused it. 
(2) The authors should include the ERCP pictures. Were the filling defects in the distal part of the 
duct, ie distal to the fistula? If so, this would support the diagnosis of a sump syndrome. Why was 
the fistula not seen at ERCP? It seems surprising that such a large fistula could have been missed. If 
it was not seen at ERCP, it could be argued that the fistula could have been created iatrogenically at 
the time of her recent surgery. 
(3) The authors have not discussed a few relevant case series and reports (HPB surgery 1993 and 
Foreign material as a cause of choledocholithiasis, Endoscopy 1999). They should discuss these 
papers. (4) The authors main recommendation is that there should be greater awareness of biliary bezoars 
in the setting of a choledochoduodenal fistula at the time of ERCP so that more intensive efforts are 
made to clear the duct endoscopically. How can the endoscopist tell at the time of ERCP whether 
they are bezoars or stones? ------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the 
author can be trusted to correct) (1) The authors keep using the word "stones" from the bile duct when in fact they were actually bezoars. This is confusing and should be clarified. 
(2) There are a few grammatical mistakes throughout the text, eg 2nd paragraph, page 2 "We report 
a recent experience with obstructive jaundice following a bezoar development ....". The grammar 
needs to be checked and corrected. (3)Page 3, paragraph 3 - "scout films": did the authors not mean cholangiogram? 
(4)The authors need to give more details of the ERCP. Was a sphincterotomy performed? Why 
could the stones not be removed? Did they attempt lithotripsy? In many cases, surprisingly large stones can be removed following lithotripsy. 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
 Unable to decide on acceptance or rejection until the authors have responded to the What next?: 
major compulsory revisions 
 An article of limited interest Level of interest: 
 Needs some language corrections before being published Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests. 
Please review this paper.
user
Reviewer's report 
 Development of bile duct bezoar after cholecystectomy caused by choledochoduodenal fistula Title: 
formation: case report 
 1  10 August 2005 Version: Date: 
 Tony C Tham Reviewer: 
Reviewer's report: 
General 
The authors describe a case of a patient found to have a biliary bezoar thought to be caused by a choledochoduodenal fistula. ------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can 
be reached) 
(1) It is not clear what caused the fistula: could it have been a surgical fistula (choledochoduodenostomy) created at the time of her cholecystectomy 6 years ago? If this was 
surgically created, the authors could be describing the sump syndrome which is a well recognised 
complication of a choledochoduodenostomy. The authors need to be clear on this point because if they assume that this was a spontaneous fistula, they have to explain what caused it. 
(2) The authors should include the ERCP pictures. Were the filling defects in the distal part of the 
duct, ie distal to the fistula? If so, this would support the diagnosis of a sump syndrome. Why was 
the fistula not seen at ERCP? It seems surprising that such a large fistula could have been missed. If 
it was not seen at ERCP, it could be argued that the fistula could have been created iatrogenically at 
the time of her recent surgery. 
(3) The authors have not discussed a few relevant case series and reports (HPB surgery 1993 and 
Foreign material as a cause of choledocholithiasis, Endoscopy 1999). They should discuss these 
papers. (4) The authors main recommendation is that there should be greater awareness of biliary bezoars 
in the setting of a choledochoduodenal fistula at the time of ERCP so that more intensive efforts are 
made to clear the duct endoscopically. How can the endoscopist tell at the time of ERCP whether 
they are bezoars or stones? ------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the 
author can be trusted to correct) (1) The authors keep using the word "stones" from the bile duct when in fact they were actually bezoars. This is confusing and should be clarified. 
(2) There are a few grammatical mistakes throughout the text, eg 2nd paragraph, page 2 "We report 
a recent experience with obstructive jaundice following a bezoar development ....". The grammar 
needs to be checked and corrected. (3)Page 3, paragraph 3 - "scout films": did the authors not mean cholangiogram? 
(4)The authors need to give more details of the ERCP. Was a sphincterotomy performed? Why 
could the stones not be removed? Did they attempt lithotripsy? In many cases, surprisingly large stones can be removed following lithotripsy. 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
 Unable to decide on acceptance or rejection until the authors have responded to the What next?: 
major compulsory revisions 
 An article of limited interest Level of interest: 
 Needs some language corrections before being published Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests. 
assistant