Reviewer’s report
Title: 
Granulomatous cholangitis mimicking hilar cholangiocarcinoma: A case
report
Version: 
0 
Date: 
01 Oct 2020
Reviewer's report:
- a case report on a rare condition should, among all, guide clinical reasoning of
the physician to reach a correct diagnosis, by excluding step-by step all the other
disorders, starting from the most common ones. Hence, I would have described
in more details patient's anamnesis (i.e. family history of hepatobiliary disorders;
medications; recent travel history; history of alcohol/drugs consumption;
exposure to thorotrast; possible exposure to liver flukes such as Opisthorchis
viverini and Clonorchis sinensis). 
- among the laboratory exams, you have correctly assessed for the positivity of
ANA in the suspect of AIH. Being ANA 1:320 a diagnostic parameter for AIH,
have you checked for the presence of second level antibodies (ASMA, SLA/LP,
LKM, LC1)? Have you assessed total IgG? If so, I would mention it, since we
are talking of a relatively young and healthy woman with new and rapid onset of
liver markers alteration. Furthermore, since AIH was excluded, are there possible
reasons for ANA positivity? 
-I would add some relevant information about the clinical course of the disease.
In particular, has the patient remained apyretic for the whole time? Have her
blood analysis and vital signs remained similar to the ones of referral?
-Since blood exams at the time of referral showed evidence of increased
inflammatory markers, even if the patient was not febrile, were blood and urine
cultures assessed? Furthermore, have you assessed stools samples (in particular
looking for parasitic infections)?
-The phrase used in the discussion "it is desirable to avoid excessive invasion if
there is a possibility of benign disease" in my opinion should be better explained.
How can you be sure of the malignancy of the disease before surgery?
-Since the initial diagnostic suspect was the one of cholangiocarcinoma, an
highly aggressive and metastatic tumor, have you assessed for the presence of
distant metastasis by performing a total body (not only abdomen) CT scan; MR
or PET before surgical intervention? if so, I would mention it.  
Publons Reviewer Recognition
. Springer Nature can send verification of this
review directly to Publons (a subsidiary of Clarivate Analytics). If you would
like to take advantage of this service, please click on the “Yes” option below.
Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted
to Publons upon publication of the manuscript. If you have already registered at
Publons, they will notify you of the receipt of this review and update your profile
as per your settings and their policy. If you are not registered with Publons, you
will receive an email from them asking you to register in order for them to be
able to recognize your review on your new profile page. Publons may use the
Review Data to generate derivative metadata for the benefit of Publons and you
as a reviewer, carefully considering the sensitivity of such information. For
example, Publons may verify your record as a reviewer by updating your profile
published on its webservice if you have registered for such service or help
editors to identify candidate reviewers. Please find the details of processing in
Publons’ privacy policy 
https://publons.com/about/terms
No
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 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 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
Reviewer Publication Consent.
 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
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
Reviewer’s report
Title: 
Granulomatous cholangitis mimicking hilar cholangiocarcinoma: A case
report
Version: 
0 
Date: 
01 Oct 2020
Reviewer's report:
- a case report on a rare condition should, among all, guide clinical reasoning of
the physician to reach a correct diagnosis, by excluding step-by step all the other
disorders, starting from the most common ones. Hence, I would have described
in more details patient's anamnesis (i.e. family history of hepatobiliary disorders;
medications; recent travel history; history of alcohol/drugs consumption;
exposure to thorotrast; possible exposure to liver flukes such as Opisthorchis
viverini and Clonorchis sinensis). 
- among the laboratory exams, you have correctly assessed for the positivity of
ANA in the suspect of AIH. Being ANA 1:320 a diagnostic parameter for AIH,
have you checked for the presence of second level antibodies (ASMA, SLA/LP,
LKM, LC1)? Have you assessed total IgG? If so, I would mention it, since we
are talking of a relatively young and healthy woman with new and rapid onset of
liver markers alteration. Furthermore, since AIH was excluded, are there possible
reasons for ANA positivity? 
-I would add some relevant information about the clinical course of the disease.
In particular, has the patient remained apyretic for the whole time? Have her
blood analysis and vital signs remained similar to the ones of referral?
-Since blood exams at the time of referral showed evidence of increased
inflammatory markers, even if the patient was not febrile, were blood and urine
cultures assessed? Furthermore, have you assessed stools samples (in particular
looking for parasitic infections)?
-The phrase used in the discussion "it is desirable to avoid excessive invasion if
there is a possibility of benign disease" in my opinion should be better explained.
How can you be sure of the malignancy of the disease before surgery?
-Since the initial diagnostic suspect was the one of cholangiocarcinoma, an
highly aggressive and metastatic tumor, have you assessed for the presence of
distant metastasis by performing a total body (not only abdomen) CT scan; MR
or PET before surgical intervention? if so, I would mention it.  
Publons Reviewer Recognition
. Springer Nature can send verification of this
review directly to Publons (a subsidiary of Clarivate Analytics). If you would
like to take advantage of this service, please click on the “Yes” option below.
Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted
to Publons upon publication of the manuscript. If you have already registered at
Publons, they will notify you of the receipt of this review and update your profile
as per your settings and their policy. If you are not registered with Publons, you
will receive an email from them asking you to register in order for them to be
able to recognize your review on your new profile page. Publons may use the
Review Data to generate derivative metadata for the benefit of Publons and you
as a reviewer, carefully considering the sensitivity of such information. For
example, Publons may verify your record as a reviewer by updating your profile
published on its webservice if you have registered for such service or help
editors to identify candidate reviewers. Please find the details of processing in
Publons’ privacy policy 
https://publons.com/about/terms
No
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 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 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
Reviewer Publication Consent.
 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
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
Please review this paper.
user
Reviewer’s report
Title: 
Granulomatous cholangitis mimicking hilar cholangiocarcinoma: A case
report
Version: 
0 
Date: 
01 Oct 2020
Reviewer's report:
- a case report on a rare condition should, among all, guide clinical reasoning of
the physician to reach a correct diagnosis, by excluding step-by step all the other
disorders, starting from the most common ones. Hence, I would have described
in more details patient's anamnesis (i.e. family history of hepatobiliary disorders;
medications; recent travel history; history of alcohol/drugs consumption;
exposure to thorotrast; possible exposure to liver flukes such as Opisthorchis
viverini and Clonorchis sinensis). 
- among the laboratory exams, you have correctly assessed for the positivity of
ANA in the suspect of AIH. Being ANA 1:320 a diagnostic parameter for AIH,
have you checked for the presence of second level antibodies (ASMA, SLA/LP,
LKM, LC1)? Have you assessed total IgG? If so, I would mention it, since we
are talking of a relatively young and healthy woman with new and rapid onset of
liver markers alteration. Furthermore, since AIH was excluded, are there possible
reasons for ANA positivity? 
-I would add some relevant information about the clinical course of the disease.
In particular, has the patient remained apyretic for the whole time? Have her
blood analysis and vital signs remained similar to the ones of referral?
-Since blood exams at the time of referral showed evidence of increased
inflammatory markers, even if the patient was not febrile, were blood and urine
cultures assessed? Furthermore, have you assessed stools samples (in particular
looking for parasitic infections)?
-The phrase used in the discussion "it is desirable to avoid excessive invasion if
there is a possibility of benign disease" in my opinion should be better explained.
How can you be sure of the malignancy of the disease before surgery?
-Since the initial diagnostic suspect was the one of cholangiocarcinoma, an
highly aggressive and metastatic tumor, have you assessed for the presence of
distant metastasis by performing a total body (not only abdomen) CT scan; MR
or PET before surgical intervention? if so, I would mention it.  
Publons Reviewer Recognition
. Springer Nature can send verification of this
review directly to Publons (a subsidiary of Clarivate Analytics). If you would
like to take advantage of this service, please click on the “Yes” option below.
Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted
to Publons upon publication of the manuscript. If you have already registered at
Publons, they will notify you of the receipt of this review and update your profile
as per your settings and their policy. If you are not registered with Publons, you
will receive an email from them asking you to register in order for them to be
able to recognize your review on your new profile page. Publons may use the
Review Data to generate derivative metadata for the benefit of Publons and you
as a reviewer, carefully considering the sensitivity of such information. For
example, Publons may verify your record as a reviewer by updating your profile
published on its webservice if you have registered for such service or help
editors to identify candidate reviewers. Please find the details of processing in
Publons’ privacy policy 
https://publons.com/about/terms
No
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 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 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
Reviewer Publication Consent.
 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
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
assistant