Reviewer ’s report  
 
Title:  Submucosal hematoma: a new distinctive sign during emergency upper digestive 
endoscopy for ammonia ingestion  
 
Version: 0 Date: 30 Dec 2016 
 
Reviewer:  Sajan Jiv Singh  Nagpal  
 
Reviewer’s report:  
 
Very nicely presented data, but the study deals with the shortcomings of rare presentations, as 
expected. The study does make a case for submucosal hematomas as a possible sign of ammonia 
ingestion. I have the following questions.  
 
1. The authors do not present comparative data from the use of other alkalis. A comparison group 
from within the same institution would have made for an even more robust study, comparing 
other alkalis versus ammonia. Has this also been seen in ingestion from other alkalis, on i nitial or 
follow up endoscopy?  
 
2. If not, do we have a possible explanation of what makes ammoniacal ingestions unique.  
 
3. Only 1/3rd of patients had the sign that the authors are presenting as 'distinctive'. I would have 
hoped that the sign was seen in at  least a majority of the patients for it to be associated. 
Moreover, as management is conservative, the identification of an association does not change 
clinical practice, which remains similar to other alkali ingestions.  
 
4. What is the exact percentage of  patients with hematoma, that also underwent a CT scan? 
Because, patients with obvious perforations were excluded, what if the hematomas are 
contained/early perforations that were never diagnosed because of lack of CT scanning, and 
ended up getting endosco py? 
 
5. Submucosal hematomas elsewhere (e.g in the esophagus) can be precipitated with vigorous 
retching, mostly in patients with ongoing anticoagulation, but can happen without it as well. 
Ammonia has a particular pungent odour as compared to other househo ld alkalis. Were there 
patients retching and vomiting a lot? That could also explain the severity of oropharyngeal 
lesions seen in these patients due to repeated exposure.  
 
6. Grammar needs to be corrected for better understanding throughout the manuscript.  
 
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.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
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 competing interests,  considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that 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 relating to the content of th e 
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 interests?  
 
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 interests' 
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 understand that my name will be included 
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments 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 und erstand that any comments 
which I do not wish to be included in my named report can be included 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:  Submucosal hematoma: a new distinctive sign during emergency upper digestive 
endoscopy for ammonia ingestion  
 
Version: 0 Date: 30 Dec 2016 
 
Reviewer:  Sajan Jiv Singh  Nagpal  
 
Reviewer’s report:  
 
Very nicely presented data, but the study deals with the shortcomings of rare presentations, as 
expected. The study does make a case for submucosal hematomas as a possible sign of ammonia 
ingestion. I have the following questions.  
 
1. The authors do not present comparative data from the use of other alkalis. A comparison group 
from within the same institution would have made for an even more robust study, comparing 
other alkalis versus ammonia. Has this also been seen in ingestion from other alkalis, on i nitial or 
follow up endoscopy?  
 
2. If not, do we have a possible explanation of what makes ammoniacal ingestions unique.  
 
3. Only 1/3rd of patients had the sign that the authors are presenting as 'distinctive'. I would have 
hoped that the sign was seen in at  least a majority of the patients for it to be associated. 
Moreover, as management is conservative, the identification of an association does not change 
clinical practice, which remains similar to other alkali ingestions.  
 
4. What is the exact percentage of  patients with hematoma, that also underwent a CT scan? 
Because, patients with obvious perforations were excluded, what if the hematomas are 
contained/early perforations that were never diagnosed because of lack of CT scanning, and 
ended up getting endosco py? 
 
5. Submucosal hematomas elsewhere (e.g in the esophagus) can be precipitated with vigorous 
retching, mostly in patients with ongoing anticoagulation, but can happen without it as well. 
Ammonia has a particular pungent odour as compared to other househo ld alkalis. Were there 
patients retching and vomiting a lot? That could also explain the severity of oropharyngeal 
lesions seen in these patients due to repeated exposure.  
 
6. Grammar needs to be corrected for better understanding throughout the manuscript.  
 
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.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
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 competing interests,  considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that 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 relating to the content of th e 
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 interests?  
 
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 interests' 
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 understand that my name will be included 
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments 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 und erstand that any comments 
which I do not wish to be included in my named report can be included 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:  Submucosal hematoma: a new distinctive sign during emergency upper digestive 
endoscopy for ammonia ingestion  
 
Version: 0 Date: 30 Dec 2016 
 
Reviewer:  Sajan Jiv Singh  Nagpal  
 
Reviewer’s report:  
 
Very nicely presented data, but the study deals with the shortcomings of rare presentations, as 
expected. The study does make a case for submucosal hematomas as a possible sign of ammonia 
ingestion. I have the following questions.  
 
1. The authors do not present comparative data from the use of other alkalis. A comparison group 
from within the same institution would have made for an even more robust study, comparing 
other alkalis versus ammonia. Has this also been seen in ingestion from other alkalis, on i nitial or 
follow up endoscopy?  
 
2. If not, do we have a possible explanation of what makes ammoniacal ingestions unique.  
 
3. Only 1/3rd of patients had the sign that the authors are presenting as 'distinctive'. I would have 
hoped that the sign was seen in at  least a majority of the patients for it to be associated. 
Moreover, as management is conservative, the identification of an association does not change 
clinical practice, which remains similar to other alkali ingestions.  
 
4. What is the exact percentage of  patients with hematoma, that also underwent a CT scan? 
Because, patients with obvious perforations were excluded, what if the hematomas are 
contained/early perforations that were never diagnosed because of lack of CT scanning, and 
ended up getting endosco py? 
 
5. Submucosal hematomas elsewhere (e.g in the esophagus) can be precipitated with vigorous 
retching, mostly in patients with ongoing anticoagulation, but can happen without it as well. 
Ammonia has a particular pungent odour as compared to other househo ld alkalis. Were there 
patients retching and vomiting a lot? That could also explain the severity of oropharyngeal 
lesions seen in these patients due to repeated exposure.  
 
6. Grammar needs to be corrected for better understanding throughout the manuscript.  
 
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.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
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 competing interests,  considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that 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 relating to the content of th e 
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 interests?  
 
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 interests' 
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 understand that my name will be included 
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments 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 und erstand that any comments 
which I do not wish to be included in my named report can be included as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant