Reviewer ’s report  
 
Title:  Submucosal hematoma: a new distinctive sign during emergency upper digestive 
endoscopy for ammonia ingestion  
 
Version: 0 Date: 17 Dec 2017 
 
Reviewer:  Sandro  Contini  
 
Reviewer’s report:  
 
 This manuscript is potentially interesting, especially for the relatively new endoscopic finding, 
apparently never described and peculiar of ammonia ingestion. However there are some concerns 
about the paper.  
 
There are some minor English inaccu racies that can be improved, as well English style.  
 
Looking at the endoscopic pictures, it seems to me that the submucosal hematoma (SH) is more 
similar to a thrombosis of the submucosal vessels, which could be justified by a retrograde 
process of thrombos is from the veins of the esophageal wall, likely damaged by the caustic 
agents. Actually, all pictures are of the fundus. Could the authors show pictures of other parts of 
the stomach?  
 
The authors adfirm that "in patients with IIIB gastric lesion initially  a laparotomy was proposed 
for the gastric wall evaluation". However, not always laparoscopic/laparotomic evaluation give a 
correct assessment of the damage. Poor vascularization of the mucosa, leading to necrosis, is not 
immediately perceived on the seros a especially at the first stages and likely it is better evaluated 
at endoscopy.  
 
When gastrectomy and esophagectomy could not be performed due to the absence of an expert 
surgeon, patients were referred, some of them apparently to Europe. However, a long time 
interval before is usually considered detrimental for the outcome of patients with a surgical 
indication. It can be asked if patients who tolerated such a long referral could possibly heal 
without surgery.  
 
The authors state that "patients who failed endoscopic dilation were offered surgical treatment". 
It would be correct to know the definition of failure of endoscopic treatment.  
 
How many patients performed a CT scan followed by endoscopy? From the manuscript three 
patients after CT scan were intubat ed and managed in ICU. It would be nice to know CT scan 
findings and endoscopic findings (especially the presence of SH) of these patients..  
 
Looking at table 2, SH was much more present in patients with an ingestion of less than 150 ml 
of caustic agent an d does not increase by increasing volume of ingestion. It is paralleling what is 
found comparing endoscopic lesions and this at least should be pointed out and discussed.  
 
What is amazing to me is the authors conclude that SH can be found either in mild or in severe 
endoscopic lesions, without affecting the patient's outcome. The statement is confusing, 
comprehending a wide range of lesions and does not allow any prognostic conclusion.  
 
The authors encourage medical management, especially in centers without surgical expertise, but 
the choice between surgical and medical treatment is guided by well established principles, i.e. a 
recognized or an impending perforation. Indeed, the authors adfirm that "a medical management 
could be applied to patients presenting SH, particularly when other mild endoscopic lesions were 
associated". From this, the real value of SH can be questioned.  
 
In conclusion, this paper offers a new endoscopi c feature after caustic ingestion, which seems to 
be peculiar of ammonia ingestion. However, the paper needs to be deeply revised and possibly 
modified in the conclusion, which are not supported by significant argumentations.  
 
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 recommend additional statistical review  
 
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 h ave 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: 17 Dec 2017 
 
Reviewer:  Sandro  Contini  
 
Reviewer’s report:  
 
 This manuscript is potentially interesting, especially for the relatively new endoscopic finding, 
apparently never described and peculiar of ammonia ingestion. However there are some concerns 
about the paper.  
 
There are some minor English inaccu racies that can be improved, as well English style.  
 
Looking at the endoscopic pictures, it seems to me that the submucosal hematoma (SH) is more 
similar to a thrombosis of the submucosal vessels, which could be justified by a retrograde 
process of thrombos is from the veins of the esophageal wall, likely damaged by the caustic 
agents. Actually, all pictures are of the fundus. Could the authors show pictures of other parts of 
the stomach?  
 
The authors adfirm that "in patients with IIIB gastric lesion initially  a laparotomy was proposed 
for the gastric wall evaluation". However, not always laparoscopic/laparotomic evaluation give a 
correct assessment of the damage. Poor vascularization of the mucosa, leading to necrosis, is not 
immediately perceived on the seros a especially at the first stages and likely it is better evaluated 
at endoscopy.  
 
When gastrectomy and esophagectomy could not be performed due to the absence of an expert 
surgeon, patients were referred, some of them apparently to Europe. However, a long time 
interval before is usually considered detrimental for the outcome of patients with a surgical 
indication. It can be asked if patients who tolerated such a long referral could possibly heal 
without surgery.  
 
The authors state that "patients who failed endoscopic dilation were offered surgical treatment". 
It would be correct to know the definition of failure of endoscopic treatment.  
 
How many patients performed a CT scan followed by endoscopy? From the manuscript three 
patients after CT scan were intubat ed and managed in ICU. It would be nice to know CT scan 
findings and endoscopic findings (especially the presence of SH) of these patients..  
 
Looking at table 2, SH was much more present in patients with an ingestion of less than 150 ml 
of caustic agent an d does not increase by increasing volume of ingestion. It is paralleling what is 
found comparing endoscopic lesions and this at least should be pointed out and discussed.  
 
What is amazing to me is the authors conclude that SH can be found either in mild or in severe 
endoscopic lesions, without affecting the patient's outcome. The statement is confusing, 
comprehending a wide range of lesions and does not allow any prognostic conclusion.  
 
The authors encourage medical management, especially in centers without surgical expertise, but 
the choice between surgical and medical treatment is guided by well established principles, i.e. a 
recognized or an impending perforation. Indeed, the authors adfirm that "a medical management 
could be applied to patients presenting SH, particularly when other mild endoscopic lesions were 
associated". From this, the real value of SH can be questioned.  
 
In conclusion, this paper offers a new endoscopi c feature after caustic ingestion, which seems to 
be peculiar of ammonia ingestion. However, the paper needs to be deeply revised and possibly 
modified in the conclusion, which are not supported by significant argumentations.  
 
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 recommend additional statistical review  
 
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 h ave 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: 17 Dec 2017 
 
Reviewer:  Sandro  Contini  
 
Reviewer’s report:  
 
 This manuscript is potentially interesting, especially for the relatively new endoscopic finding, 
apparently never described and peculiar of ammonia ingestion. However there are some concerns 
about the paper.  
 
There are some minor English inaccu racies that can be improved, as well English style.  
 
Looking at the endoscopic pictures, it seems to me that the submucosal hematoma (SH) is more 
similar to a thrombosis of the submucosal vessels, which could be justified by a retrograde 
process of thrombos is from the veins of the esophageal wall, likely damaged by the caustic 
agents. Actually, all pictures are of the fundus. Could the authors show pictures of other parts of 
the stomach?  
 
The authors adfirm that "in patients with IIIB gastric lesion initially  a laparotomy was proposed 
for the gastric wall evaluation". However, not always laparoscopic/laparotomic evaluation give a 
correct assessment of the damage. Poor vascularization of the mucosa, leading to necrosis, is not 
immediately perceived on the seros a especially at the first stages and likely it is better evaluated 
at endoscopy.  
 
When gastrectomy and esophagectomy could not be performed due to the absence of an expert 
surgeon, patients were referred, some of them apparently to Europe. However, a long time 
interval before is usually considered detrimental for the outcome of patients with a surgical 
indication. It can be asked if patients who tolerated such a long referral could possibly heal 
without surgery.  
 
The authors state that "patients who failed endoscopic dilation were offered surgical treatment". 
It would be correct to know the definition of failure of endoscopic treatment.  
 
How many patients performed a CT scan followed by endoscopy? From the manuscript three 
patients after CT scan were intubat ed and managed in ICU. It would be nice to know CT scan 
findings and endoscopic findings (especially the presence of SH) of these patients..  
 
Looking at table 2, SH was much more present in patients with an ingestion of less than 150 ml 
of caustic agent an d does not increase by increasing volume of ingestion. It is paralleling what is 
found comparing endoscopic lesions and this at least should be pointed out and discussed.  
 
What is amazing to me is the authors conclude that SH can be found either in mild or in severe 
endoscopic lesions, without affecting the patient's outcome. The statement is confusing, 
comprehending a wide range of lesions and does not allow any prognostic conclusion.  
 
The authors encourage medical management, especially in centers without surgical expertise, but 
the choice between surgical and medical treatment is guided by well established principles, i.e. a 
recognized or an impending perforation. Indeed, the authors adfirm that "a medical management 
could be applied to patients presenting SH, particularly when other mild endoscopic lesions were 
associated". From this, the real value of SH can be questioned.  
 
In conclusion, this paper offers a new endoscopi c feature after caustic ingestion, which seems to 
be peculiar of ammonia ingestion. However, the paper needs to be deeply revised and possibly 
modified in the conclusion, which are not supported by significant argumentations.  
 
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 recommend additional statistical review  
 
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 h ave 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