Reviewer ’s report  
 
Title: Portal hypertensive gastropathy as a prognostic index in patients with liver cirrhosis  
 
 
Version: 0 Date: 12 May 2016  
 
 
Reviewer: Douglas  Simonetto  
 
Reviewer's report:  
 
This prospective study by Bang et al evaluated the presence and severity of portal hypertensive 
gastropathy (PGH) in a large cohort of cirrhotic patients. This is the largest study to date 
correlating PGH with hepatic venous pressure gradient (HVPG). Previous  studies had shown 
conflicting results. Different groups had failed to show a correlation between PGH and severity 
of portal hypertension. These were small studies however and likely underpowered.  
 
The study by Bang et al demonstrated significant correlat ion between the severity of PGH and 
portal hypertension, as assessed by HVPG. These findings are consistent with a previous Korean 
study (Kim et al. Dig Dis Sci. 2010 Dec;55(12):3561 -7) and also suggest that decrease in portal 
pressures may lead to improve ment of PHG  (Kamath et al. Gastroenterology. 2000 
May;118(5):905 -11). 
 
Not surprisingly, the severity of PHG and portal hypertension also correlated with MELD and 
Child -Pugh scores, and consequently with worse survival. The authors however have not 
repeat ed endoscopic or HVPG assessment overtime for the development of PHG and progression 
of portal hypertension.   
 
Two important pieces of information are missing however in this study. One, is the presence of 
gastroesophageal varices, previous endoscopic tre atments and the use of nonselective beta -
blockers. This data should be readily available to the authors and it should be included in the 
results. Previous endoscopic therapy (band ligation or sclerotherapy) for esophageal varices may 
worsen PHG, and increa se the risk of PHG -related bleeding (Lo et al. Gastrointest Endosc. 2001 
May;53(6):579 -84.). Therefore, the authors should perform separate subgroup analyzes, 
excluding those with previous endoscopic therapies, which are more likely in severe portal 
hypert ension (higher HVPG).  
 
The second important missing part, is the distinction between PHG and gastric antral vascular 
ectasia (GAVE). These two conditions can be easily confused and the latter is not associated 
with severity of portal hypertension. The auth ors should mention in the methods how GAVE was 
excluded and ideally report the prevalence of this finding.  
 
OTHER POINTS  
 
- Report the number of cases of disagreement that required group review.  
- The authors should report the average time elapsed between  HVPG measurement and the 
EGD.  
- The MELD scores were surprisingly low; please clarify when was the MELD calculated 
(if at time of HVPG/EGD).  
- Please revise table 2. The MELD on the "No PHG" group is unclear. Is this the real 
range? The lowest possible M ELD score should 6.   
- Were the endoscopists blinded to the presence or severity of the liver disease/portal 
hypertension?  
 
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.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in th e 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 wri tten English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please compl ete 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 th is 
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 applyi ng 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 y es 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 publicat ion, 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 understand 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: Portal hypertensive gastropathy as a prognostic index in patients with liver cirrhosis  
 
 
Version: 0 Date: 12 May 2016  
 
 
Reviewer: Douglas  Simonetto  
 
Reviewer's report:  
 
This prospective study by Bang et al evaluated the presence and severity of portal hypertensive 
gastropathy (PGH) in a large cohort of cirrhotic patients. This is the largest study to date 
correlating PGH with hepatic venous pressure gradient (HVPG). Previous  studies had shown 
conflicting results. Different groups had failed to show a correlation between PGH and severity 
of portal hypertension. These were small studies however and likely underpowered.  
 
The study by Bang et al demonstrated significant correlat ion between the severity of PGH and 
portal hypertension, as assessed by HVPG. These findings are consistent with a previous Korean 
study (Kim et al. Dig Dis Sci. 2010 Dec;55(12):3561 -7) and also suggest that decrease in portal 
pressures may lead to improve ment of PHG  (Kamath et al. Gastroenterology. 2000 
May;118(5):905 -11). 
 
Not surprisingly, the severity of PHG and portal hypertension also correlated with MELD and 
Child -Pugh scores, and consequently with worse survival. The authors however have not 
repeat ed endoscopic or HVPG assessment overtime for the development of PHG and progression 
of portal hypertension.   
 
Two important pieces of information are missing however in this study. One, is the presence of 
gastroesophageal varices, previous endoscopic tre atments and the use of nonselective beta -
blockers. This data should be readily available to the authors and it should be included in the 
results. Previous endoscopic therapy (band ligation or sclerotherapy) for esophageal varices may 
worsen PHG, and increa se the risk of PHG -related bleeding (Lo et al. Gastrointest Endosc. 2001 
May;53(6):579 -84.). Therefore, the authors should perform separate subgroup analyzes, 
excluding those with previous endoscopic therapies, which are more likely in severe portal 
hypert ension (higher HVPG).  
 
The second important missing part, is the distinction between PHG and gastric antral vascular 
ectasia (GAVE). These two conditions can be easily confused and the latter is not associated 
with severity of portal hypertension. The auth ors should mention in the methods how GAVE was 
excluded and ideally report the prevalence of this finding.  
 
OTHER POINTS  
 
- Report the number of cases of disagreement that required group review.  
- The authors should report the average time elapsed between  HVPG measurement and the 
EGD.  
- The MELD scores were surprisingly low; please clarify when was the MELD calculated 
(if at time of HVPG/EGD).  
- Please revise table 2. The MELD on the "No PHG" group is unclear. Is this the real 
range? The lowest possible M ELD score should 6.   
- Were the endoscopists blinded to the presence or severity of the liver disease/portal 
hypertension?  
 
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.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in th e 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 wri tten English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please compl ete 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 th is 
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 applyi ng 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 y es 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 publicat ion, 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 understand 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: Portal hypertensive gastropathy as a prognostic index in patients with liver cirrhosis  
 
 
Version: 0 Date: 12 May 2016  
 
 
Reviewer: Douglas  Simonetto  
 
Reviewer's report:  
 
This prospective study by Bang et al evaluated the presence and severity of portal hypertensive 
gastropathy (PGH) in a large cohort of cirrhotic patients. This is the largest study to date 
correlating PGH with hepatic venous pressure gradient (HVPG). Previous  studies had shown 
conflicting results. Different groups had failed to show a correlation between PGH and severity 
of portal hypertension. These were small studies however and likely underpowered.  
 
The study by Bang et al demonstrated significant correlat ion between the severity of PGH and 
portal hypertension, as assessed by HVPG. These findings are consistent with a previous Korean 
study (Kim et al. Dig Dis Sci. 2010 Dec;55(12):3561 -7) and also suggest that decrease in portal 
pressures may lead to improve ment of PHG  (Kamath et al. Gastroenterology. 2000 
May;118(5):905 -11). 
 
Not surprisingly, the severity of PHG and portal hypertension also correlated with MELD and 
Child -Pugh scores, and consequently with worse survival. The authors however have not 
repeat ed endoscopic or HVPG assessment overtime for the development of PHG and progression 
of portal hypertension.   
 
Two important pieces of information are missing however in this study. One, is the presence of 
gastroesophageal varices, previous endoscopic tre atments and the use of nonselective beta -
blockers. This data should be readily available to the authors and it should be included in the 
results. Previous endoscopic therapy (band ligation or sclerotherapy) for esophageal varices may 
worsen PHG, and increa se the risk of PHG -related bleeding (Lo et al. Gastrointest Endosc. 2001 
May;53(6):579 -84.). Therefore, the authors should perform separate subgroup analyzes, 
excluding those with previous endoscopic therapies, which are more likely in severe portal 
hypert ension (higher HVPG).  
 
The second important missing part, is the distinction between PHG and gastric antral vascular 
ectasia (GAVE). These two conditions can be easily confused and the latter is not associated 
with severity of portal hypertension. The auth ors should mention in the methods how GAVE was 
excluded and ideally report the prevalence of this finding.  
 
OTHER POINTS  
 
- Report the number of cases of disagreement that required group review.  
- The authors should report the average time elapsed between  HVPG measurement and the 
EGD.  
- The MELD scores were surprisingly low; please clarify when was the MELD calculated 
(if at time of HVPG/EGD).  
- Please revise table 2. The MELD on the "No PHG" group is unclear. Is this the real 
range? The lowest possible M ELD score should 6.   
- Were the endoscopists blinded to the presence or severity of the liver disease/portal 
hypertension?  
 
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.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in th e 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 wri tten English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please compl ete 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 th is 
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 applyi ng 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 y es 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 publicat ion, 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 understand 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