Reviewer ’s report  
 
Title:  Severe colonic bleeding in ulcerative colitis is refractory to selective transcatheter arterial 
embolization  
 
Version: 0 Date: 29 Dec 2018 
 
Reviewer:  Yen-Po Wang  
 
Reviewer’s report:  
 
This is a case series addressing 3 cases using transarterial embolization to treat ulcerative colitis 
patients with active arter ial bleeding. 3 cases all had rebleeding after transarterial embolization 
and received colectomy after then. However, there's one key question that the authors didn't 
clearly explained that did these 3 patients' ulcerative colitis respond to pharmacologic therapy or 
not? In the article, it seemed that they didn't respond to pharmacologic therapy. For acute severe 
ulcerative colitis patients who failed steroids and anti -TNF alpha, colectomy was the treatment of 
choice. The patients should receive colectomy d ue to poor response to medication, not due to 
acute arterial bleeding.  So even when doctors found the arterial bleeding, if the patient failed 
pharmacologic treatment, then they should receive surgery. If their mucosa, inflammation 
improved after pharmaco logic treatment, there are still no evidence about role of transarterial 
embolization yet.  Transarterial embolization is used to treat localized bleeding, that can't treat 
the whole colon multifocal bleeding in theory. The detailed questions are as follow ing: 
 
 
Major issues:  
 
1. For all three cases, what's the edinburgh index, stool frequence, CRP level after 3 days after 
IV steroids treatment?  
 
2. What are the MAYO score and UCEIS score about the 3 patients.  
 
3. In these 3 cases of fulminant UC, did the patie nts  receive venous embolization prophylaxis 
with clexane or other anticoagulants as consensus suggested? If yes, please comment about it  
and discuss about their relation with bleeding. If no, please explain why.  
 
(Kornbluth A et al. Am J Gastroenterol. 2 010;105:501 -23; Travis SP et al.  J Crohns Colitis. 
2008;2:24 -62. Mowat C, et al. Gut. 2011;60:571 -607.; Bitton A et al. Am J Gastroenterol. 
2012;107:179 -94. ) 
 
4. In case 1, why the patients needed infliximab  if steroids worked? or the patient didn't work  
well enough? What is condion after 3 days IV steroids treatment?  
 
5. In case 2 and 3, where was the bleeding site finally? the same site as angiography showed? or 
other places?  
 
6. Why endoscopic wasn't considered in these 3 cases since the bleeding site w as found. (Oshima 
T et al. Dig Dis Sci. 2007 Jun;52(6):1434 -7. Epub 2007 Apr 3.)  
 
7. The authors may clarify use of TAE in IBD or UC is not suitable, since there are also recent 
papers addressing that TAE worked in Crohn's disease.  (Martín, V., Rubí, A. R. , Chaparro, M., 
Jusué, V., Friera, A., & Gisbert, J. P. (2013). Embolización arterial en el tratamiento de la 
hemorragia digestiva baja masiva en los pacientes con enfermedad de Crohn. Gastroenterología 
y Hepatología, 36(9), 574 -576. )  
 
 
Minor issues:  
 
Some typo errors and grammar problems noted in this article, please recheck them. Some 
examples are as following but not limited to following  
 
1.  Introduction, line 6, According should be changed to according to  
 
2.  Case 1 , line 14 , after infliximab first do se may be changed to first dose of infliximab  
 
3.  For Case 2, line 16, although clinical situation initially became steady, may be changed as 
although clinical situation became steady initially.  
 
4.  Case2, urgent laparoscopic subtotal colectomy and termina l ileostomy was accomplished  
may be modified as  urgent laparoscopic subtotal colectomy and termina lileostomy were done.  
 
5.  Line 18 . Adequate evolution thereafter permitted discharge with corticosteroid tapering. 
made me a little confusing that who per mitted? or what permitted?  
 
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.  
 
Unable to assess  
 
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.  
 
Not relevant to this manuscript  
 
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 q uestions:  
 
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.  
 
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 understand that any comments 
which I do not wish to be includ ed 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:  Severe colonic bleeding in ulcerative colitis is refractory to selective transcatheter arterial 
embolization  
 
Version: 0 Date: 29 Dec 2018 
 
Reviewer:  Yen-Po Wang  
 
Reviewer’s report:  
 
This is a case series addressing 3 cases using transarterial embolization to treat ulcerative colitis 
patients with active arter ial bleeding. 3 cases all had rebleeding after transarterial embolization 
and received colectomy after then. However, there's one key question that the authors didn't 
clearly explained that did these 3 patients' ulcerative colitis respond to pharmacologic therapy or 
not? In the article, it seemed that they didn't respond to pharmacologic therapy. For acute severe 
ulcerative colitis patients who failed steroids and anti -TNF alpha, colectomy was the treatment of 
choice. The patients should receive colectomy d ue to poor response to medication, not due to 
acute arterial bleeding.  So even when doctors found the arterial bleeding, if the patient failed 
pharmacologic treatment, then they should receive surgery. If their mucosa, inflammation 
improved after pharmaco logic treatment, there are still no evidence about role of transarterial 
embolization yet.  Transarterial embolization is used to treat localized bleeding, that can't treat 
the whole colon multifocal bleeding in theory. The detailed questions are as follow ing: 
 
 
Major issues:  
 
1. For all three cases, what's the edinburgh index, stool frequence, CRP level after 3 days after 
IV steroids treatment?  
 
2. What are the MAYO score and UCEIS score about the 3 patients.  
 
3. In these 3 cases of fulminant UC, did the patie nts  receive venous embolization prophylaxis 
with clexane or other anticoagulants as consensus suggested? If yes, please comment about it  
and discuss about their relation with bleeding. If no, please explain why.  
 
(Kornbluth A et al. Am J Gastroenterol. 2 010;105:501 -23; Travis SP et al.  J Crohns Colitis. 
2008;2:24 -62. Mowat C, et al. Gut. 2011;60:571 -607.; Bitton A et al. Am J Gastroenterol. 
2012;107:179 -94. ) 
 
4. In case 1, why the patients needed infliximab  if steroids worked? or the patient didn't work  
well enough? What is condion after 3 days IV steroids treatment?  
 
5. In case 2 and 3, where was the bleeding site finally? the same site as angiography showed? or 
other places?  
 
6. Why endoscopic wasn't considered in these 3 cases since the bleeding site w as found. (Oshima 
T et al. Dig Dis Sci. 2007 Jun;52(6):1434 -7. Epub 2007 Apr 3.)  
 
7. The authors may clarify use of TAE in IBD or UC is not suitable, since there are also recent 
papers addressing that TAE worked in Crohn's disease.  (Martín, V., Rubí, A. R. , Chaparro, M., 
Jusué, V., Friera, A., & Gisbert, J. P. (2013). Embolización arterial en el tratamiento de la 
hemorragia digestiva baja masiva en los pacientes con enfermedad de Crohn. Gastroenterología 
y Hepatología, 36(9), 574 -576. )  
 
 
Minor issues:  
 
Some typo errors and grammar problems noted in this article, please recheck them. Some 
examples are as following but not limited to following  
 
1.  Introduction, line 6, According should be changed to according to  
 
2.  Case 1 , line 14 , after infliximab first do se may be changed to first dose of infliximab  
 
3.  For Case 2, line 16, although clinical situation initially became steady, may be changed as 
although clinical situation became steady initially.  
 
4.  Case2, urgent laparoscopic subtotal colectomy and termina l ileostomy was accomplished  
may be modified as  urgent laparoscopic subtotal colectomy and termina lileostomy were done.  
 
5.  Line 18 . Adequate evolution thereafter permitted discharge with corticosteroid tapering. 
made me a little confusing that who per mitted? or what permitted?  
 
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.  
 
Unable to assess  
 
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.  
 
Not relevant to this manuscript  
 
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 q uestions:  
 
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.  
 
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 understand that any comments 
which I do not wish to be includ ed 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:  Severe colonic bleeding in ulcerative colitis is refractory to selective transcatheter arterial 
embolization  
 
Version: 0 Date: 29 Dec 2018 
 
Reviewer:  Yen-Po Wang  
 
Reviewer’s report:  
 
This is a case series addressing 3 cases using transarterial embolization to treat ulcerative colitis 
patients with active arter ial bleeding. 3 cases all had rebleeding after transarterial embolization 
and received colectomy after then. However, there's one key question that the authors didn't 
clearly explained that did these 3 patients' ulcerative colitis respond to pharmacologic therapy or 
not? In the article, it seemed that they didn't respond to pharmacologic therapy. For acute severe 
ulcerative colitis patients who failed steroids and anti -TNF alpha, colectomy was the treatment of 
choice. The patients should receive colectomy d ue to poor response to medication, not due to 
acute arterial bleeding.  So even when doctors found the arterial bleeding, if the patient failed 
pharmacologic treatment, then they should receive surgery. If their mucosa, inflammation 
improved after pharmaco logic treatment, there are still no evidence about role of transarterial 
embolization yet.  Transarterial embolization is used to treat localized bleeding, that can't treat 
the whole colon multifocal bleeding in theory. The detailed questions are as follow ing: 
 
 
Major issues:  
 
1. For all three cases, what's the edinburgh index, stool frequence, CRP level after 3 days after 
IV steroids treatment?  
 
2. What are the MAYO score and UCEIS score about the 3 patients.  
 
3. In these 3 cases of fulminant UC, did the patie nts  receive venous embolization prophylaxis 
with clexane or other anticoagulants as consensus suggested? If yes, please comment about it  
and discuss about their relation with bleeding. If no, please explain why.  
 
(Kornbluth A et al. Am J Gastroenterol. 2 010;105:501 -23; Travis SP et al.  J Crohns Colitis. 
2008;2:24 -62. Mowat C, et al. Gut. 2011;60:571 -607.; Bitton A et al. Am J Gastroenterol. 
2012;107:179 -94. ) 
 
4. In case 1, why the patients needed infliximab  if steroids worked? or the patient didn't work  
well enough? What is condion after 3 days IV steroids treatment?  
 
5. In case 2 and 3, where was the bleeding site finally? the same site as angiography showed? or 
other places?  
 
6. Why endoscopic wasn't considered in these 3 cases since the bleeding site w as found. (Oshima 
T et al. Dig Dis Sci. 2007 Jun;52(6):1434 -7. Epub 2007 Apr 3.)  
 
7. The authors may clarify use of TAE in IBD or UC is not suitable, since there are also recent 
papers addressing that TAE worked in Crohn's disease.  (Martín, V., Rubí, A. R. , Chaparro, M., 
Jusué, V., Friera, A., & Gisbert, J. P. (2013). Embolización arterial en el tratamiento de la 
hemorragia digestiva baja masiva en los pacientes con enfermedad de Crohn. Gastroenterología 
y Hepatología, 36(9), 574 -576. )  
 
 
Minor issues:  
 
Some typo errors and grammar problems noted in this article, please recheck them. Some 
examples are as following but not limited to following  
 
1.  Introduction, line 6, According should be changed to according to  
 
2.  Case 1 , line 14 , after infliximab first do se may be changed to first dose of infliximab  
 
3.  For Case 2, line 16, although clinical situation initially became steady, may be changed as 
although clinical situation became steady initially.  
 
4.  Case2, urgent laparoscopic subtotal colectomy and termina l ileostomy was accomplished  
may be modified as  urgent laparoscopic subtotal colectomy and termina lileostomy were done.  
 
5.  Line 18 . Adequate evolution thereafter permitted discharge with corticosteroid tapering. 
made me a little confusing that who per mitted? or what permitted?  
 
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.  
 
Unable to assess  
 
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.  
 
Not relevant to this manuscript  
 
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 q uestions:  
 
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.  
 
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 understand that any comments 
which I do not wish to be includ ed 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