Indigestible Trichobezoar Mimicking Inflammatory Bowel Disease: A Case Report and a Literature Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is a case report of a 15-year-old girl admitted and treated for trichobezoar that was initially thought to be inflammatory bowel disease. The paper is well-written. There are some comments below for author consideration in order to further improve the quality of the paper.

1. Title: This looks mostly okay except for the part that includes a review of the literature. I do not see a description of how the review was performed in the manuscript.

2. Abstract: This looks okay except for line 25. The abbreviation IBD should be spelt out before the first use.

3. Case description: Nicely done except for line 60. Correct the word "until" to "into". "...an impressive gastric-shaped trichobezoar extending until (into) the jejunum was removed (Fig. 1D)."

4. Review of the literature: A section should be included that describes the method employed in identifying and reviewing the articles cited and the findings from each of the cited articles. Otherwise, the phrase "review of the literature" should be deleted from the title.

5. Discussion: This looks good.

6. Conclusions: These look alright as well.

7. References: Look appropriate.

 

Comments on the Quality of English Language

This quality of English language is good. Only minor edits for typo and grammar are required.

Author Response

I (on behalf of all Authors) would like to submit the R1 manuscript entitled “Indigestible trichobezoar mimicking inflammatory bowel disease: a case report and a review of the literature” authored by T. Bellini, D. Franzone, F. Pezzotta, V. Andreottola, B. Lionetti, P. Gandullia, E. Piccotti and G. Mattioli.

 

We thank the reviewers for the important and long review work they have done. All this allowed us to significantly raise the level of our article. We have taken into account all the observations made and the text has been modified.

Any changes to the original text are in red font, making it easy to identify the corrections.

We hope that at this point the text of the article can satisfy the legitimate expectations of Emergency Care and Medicine and that it can obtain a positive final evaluation. Please find attached a point-by-point list of answers.

 

Query 1. We have reported the methodology with which the review was conducted.

Query 2. We have corrected the text according to Reviewer’s suggestions.

Query 3. We have corrected the file according to Reviewer’s suggestions.

Query 4. We have added a “materials and methods” paragraph.

Reviewer 2 Report

Comments and Suggestions for Authors

This case is interesting but should undergo massive revisions before publication.

The case presents a major problem that in my opinion should be addressed: Removal of a very large intragastric bezoar is described expressing that this element mimicked IBD. However, the authors describe an erosive ileopathy with negative histologic features for IBD. Very often the diagnosis of IBD is a challenge and histology, especially in Crohn's disease is often inconclusive at the time of first diagnosis. However, the authors do not expound on the results of such ileal biopsies (i.e., whether perhaps there were signs of chronic inflammation or only acute inflammation or both). Nor is it clear whether the patient then had a contrast-enhanced MRI of the small intestine to rule out other sites of intestinal involvement. Nor is it clear whether the authors made a differential diagnosis of the other forms of acute or chronic inflammatory ileopathies. Nor is it clear, when they did not do so, whether they planned and how rather they planned follow-up of both bezoar and ileopathy of undefined diagnosis.

The discussion sounds very much like a narrative review of bezoars. It should rather focus on articles related to that report. That is, they should expose cases of bezoars mimicking other gastrointestinal conditions, primarily IBD and secondarily others.

Additional Major Considerations:

- The work lacks an introduction. This is severely limiting to the formal quality of the manuscript. A succinct introduction should inevitably be included;

- Lines 38 to 40 describe a "shopping list"-like list of clinical manifestations. Each of these features has peculiar semiological elements that may direct diagnostic suspicion. It should be specified, in other words, abdominal pain in which abdominal quadrants was present, the physical examination what did it demonstrate in detail, anorexia should be better characterized, diarrhea (it should be said whether hematic, nonhematic, frequency of bowel movements, even nocturnal?). The emesis of what type was it? What was its frequency? what is meant by low-grade fever, what was the pattern of fever? What were its peaks? Was there shivers? In short it needs to be put into context;

- Line 41: I would avoid defining minor hospitals as "peripheral", rather define it as non-referral, not-high-volume hospital for such conditions.

- All laboratory items exhibited (from anemia to CRP values) should be displayed with relevant units and normal reference values (consider a table);

- Had the US performed also included digestive scans? Evaluation of stomach, small intestine and colon to explorable US segments?

- Line 46: How iron deficiency anemia has been diagnosed? Again, if possible show, for this purpose, calculated sideremia, transferrin, ferritin, and transferrin saturation levels;

- Are there images of the US and X-ray taken? If there are, maybe include them in the article;

- Line 50: Instead of saying "the patient was admitted" because it is not clear where, say "the patient was hospitalized";

- Line 50-51: again it is not clear the extent of the "non-improvement" or alleged "worsening" of the clinical picture because we do not have details of the clinical manifestations exhibited;

- Why did the patient refuse EGD? was adequate sedation proposed?

- The endoscopic description of the picture is totally superficial: the qualitative characteristics of the ileal mucosa should be described: specify its color (normal-appearing or hyperemia), the representation of the intestinal folds (normal or reduced), maximum cm extent of the retrograde ileal exploration, centimeter extent of the tract affected by the ulcers (what type? Aphthoids?) and whether there is present skipping of the ulcers with healthy mucosa interposed;

- Have biopsies been taken at the level of the ileum? I suppose yes but specify, how many? Have segmental biopsies been taken in the other sections of the colon and rectum? What are the histological findings? Are images present?;

- in the EGDS were the other segments normal? The duodenum? Were biopsies taken?

Some minor recommendations:

- I think the final part of the title could safely be changed to "[...] a case report and literature review";

- Abstract: line 19, I would recommend changing "An inflammatory bowel disease" to "Inflammatory bowel disease diagnosis [...]";

- Abstract: line 20, I would recommend changing "was considered mandatory" to "was deemed necessary".

- Abstract: I think the text from line 23 to line 33 is totally unnecessary: I would focus the abstract solely on the case description. This is not a review (although it does contain a discussion going over the cases in the literature);

- Line 55: correct "Crohn's disease".

- Line 56: "mild sedation?" What is meant? Maybe "conscious sedation"? With what? Midazolam?

- Line 59: I would avoid putting unscientific comments like "impressive."

Comments on the Quality of English Language

Refer to review report.

Author Response

I (on behalf of all Authors) would like to submit the R1 manuscript entitled “Indigestible trichobezoar mimicking inflammatory bowel disease: a case report and a review of the literature” authored by T. Bellini, D. Franzone, F. Pezzotta, V. Andreottola, B. Lionetti, P. Gandullia, E. Piccotti and G. Mattioli.

 

We thank the reviewers for the important and long review work they have done. All this allowed us to significantly raise the level of our article. We have taken into account all the observations made and the text has been modified.

Any changes to the original text are in red font, making it easy to identify the corrections.

We hope that at this point the text of the article can satisfy the legitimate expectations of Emergency Care and Medicine and that it can obtain a positive final evaluation. Please find attached a point-by-point list of answers.

Query 1. The histological report of the biopsies performed has been added.

Query 2. A small intestine contrast-enhanced MRI has not been performed.

Query 3. After the diagnosis of trichobezoar and the exclusion of infectious causes of ileitis, the patient was referred to neuropsychiatric follow-up. She did not present any further systemic and gastrointestinal symptoms. An endoscopic check-up was offered one year later but was refused and the patient was subsequently lost to follow-up.

Query 4. It is well known that primarily bezoars, whatever their nature, can cause two types of enteric diseases: intestinal obstruction or malabsorption, as we report in our review. To date, there are no clinical cases reported in which the colonoscopic examination could mimic IBD. Furthermore, we believe that an effective review of all the symptoms that can be caused by bezoars can help the clinician maintain a high clinical suspicion.

Query 5. We have included an introduction.

Query 6. We have corrected the text according to the Reviewer’s suggestion.

Query 7. We have corrected according to the Reviewer’s suggestion.

Query 8. We have provided a table according to the Reviewer’s suggestion.

Query 9. As reported in the text, the ultrasound performed on ER admission has explored the entire abdomen. we specified better that the ileo-caeco-colic loops were normal.

Query 10. Please refer to query 8.

Query 11. - the ultrasound and abdominal x-ray images, as they are normal and do not suggest a specific pathology, were not included in the article.

Query 12. We have corrected the text according to the Reviewer’s suggestion.

Query 13. We have corrected the text according to the Reviewer’s suggestion.

Query 14. We have better specified why the patient initially refused the EGDS and how it was instead carried out later. We apologize for the lack of clarity in the previous text.

Query 15. We enriched the description of the endoscopic and histopathological findings as suggested by the reviewer. Unfortunately, the exact number of biopsies performed is not reported and we have no images available.

Query 16. Macroscopic appearance of the esophagus was normal. The stomach mucosa was poorly explored due to the presence of the voluminous trichobezoar and showed aspecific erosion. The duodenum had not been explored because the pylorus was difficult to reach and, above all, due to the fear that the tail of the bezoar could break.

Query 17. We have corrected according to the Reviewer’s suggestion.

Query 18. We have corrected according to the Reviewer’s suggestion.

Query 19. We have corrected according to the Reviewer’s suggestion.

Query 20.  We are not in agreement with the reviewer as we believe that the abstract should contain both case description and brief review of the topics covered in the manuscript.

Query 21. We have corrected according to the Reviewer’s suggestion.

Query 22. We apologize for not being clear in the explanation. The patient refused the execution of the EGDS even with mild sedation with midazolam, so we temporarily overlooked the execution. At the time when IBD was suspected, EGDS was considered mandatory and therefore the patient agreed to perform EGDS under general anesthesia.

Query 23. We have corrected according to the Reviewer’s suggestion.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The revisions were done.