Case Report: Cystic artery peptic erosion: Uncommon cause of massive upper gastrointestinal bleeding.

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Our case features a cholecystoduodenal fistula presenting with severe upper gastrointestinal bleeding originating from the cystic artery. Symptoms vary, and preoperative diagnosis is uncommon. Case presentation A 63-year-old diabetic patient, who had undergone surgical treatment for a left forearm fracture, presented with persistent bleeding, hematemesis, and melena. Diagnostic esophagogastroduodenoscopy revealed an actively bleeding ulcer on the duodenal bulb, with an attempted hemostasis. Initial stabilization was achieved, but a recurrence occurred after 17 hours with hemodynamic instability. Emergency laparotomy revealed cholecystitis with a cholecystoduodenal fistula, necessitating cholecystectomy and ulcer resection. The source of bleeding was the cystic artery. The patient had a positive postoperative outcome with no recurrence of hemorrhage. Clinical discussion Cholecystoenteric fistulas, forming from obstructed cystic duct inflammation, are rare complications of biliary lithiasis. Most cases are spontaneous, linked to gallstones. Severe upper gastrointestinal bleeding from cholecystoduodenal fistulas is uncommon, often requiring surgical intervention due to cystic artery erosion. Despite advancements in laparoscopic methods, open operations are preferred for anatomical distortion and inflammation. A clear diagnosis involves hepatic angiography and may necessitate embolization. The rarity of this condition emphasizes the need for vigilant diagnosis, especially in patients with gallstone history. Conclusion Massive bleeding from cystic artery erosion by duodenal ulcer through cholecystoduodenal fistula underscores the need for clinicians’ vigilance. Recognition of gallstone disease history is crucial for timely diagnosis in this rare cause of gastrointestinal bleeding. 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F1000Research 2024, 13 :874 ( https://doi.org/10.12688/f1000research.149688.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Case Report: Cystic artery peptic erosion: Uncommon cause of massive upper gastrointestinal bleeding. [version 1; peer review: 1 approved] Med Dheker Touati https://orcid.org/0000-0002-8208-6973 1 , Wassim Dziri 1 , Rahma Yousfi 1 , Nadhem Khlifi 1 , Sana Landolsi 1 , Faouzi Chebbi 1 Med Dheker Touati https://orcid.org/0000-0002-8208-6973 1 , Wassim Dziri 1 , [...] Rahma Yousfi 1 , Nadhem Khlifi 1 , Sana Landolsi 1 , Faouzi Chebbi 1 PUBLISHED 02 Aug 2024 Author details Author details 1 Department of General Surgery, Mahmoud El Matri Hospital, Ariana, Tunisia Med Dheker Touati Roles: Writing – Original Draft Preparation Wassim Dziri Roles: Conceptualization, Writing – Original Draft Preparation Rahma Yousfi Roles: Conceptualization, Writing – Original Draft Preparation Nadhem Khlifi Roles: Writing – Original Draft Preparation Sana Landolsi Roles: Conceptualization, Writing – Review & Editing Faouzi Chebbi Roles: Supervision, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Introduction and importance The cholecystoenteric fistula, a rare complication of cholelithiasis, usually occurs as an internal biliary fistula. Our case features a cholecystoduodenal fistula presenting with severe upper gastrointestinal bleeding originating from the cystic artery. Symptoms vary, and preoperative diagnosis is uncommon. Case presentation A 63-year-old diabetic patient, who had undergone surgical treatment for a left forearm fracture, presented with persistent bleeding, hematemesis, and melena. Diagnostic esophagogastroduodenoscopy revealed an actively bleeding ulcer on the duodenal bulb, with an attempted hemostasis. Initial stabilization was achieved, but a recurrence occurred after 17 hours with hemodynamic instability. Emergency laparotomy revealed cholecystitis with a cholecystoduodenal fistula, necessitating cholecystectomy and ulcer resection. The source of bleeding was the cystic artery. The patient had a positive postoperative outcome with no recurrence of hemorrhage. Clinical discussion Cholecystoenteric fistulas, forming from obstructed cystic duct inflammation, are rare complications of biliary lithiasis. Most cases are spontaneous, linked to gallstones. Severe upper gastrointestinal bleeding from cholecystoduodenal fistulas is uncommon, often requiring surgical intervention due to cystic artery erosion. Despite advancements in laparoscopic methods, open operations are preferred for anatomical distortion and inflammation. A clear diagnosis involves hepatic angiography and may necessitate embolization. The rarity of this condition emphasizes the need for vigilant diagnosis, especially in patients with gallstone history. Conclusion Massive bleeding from cystic artery erosion by duodenal ulcer through cholecystoduodenal fistula underscores the need for clinicians’ vigilance. Recognition of gallstone disease history is crucial for timely diagnosis in this rare cause of gastrointestinal bleeding. READ ALL READ LESS Keywords Cholecystoduodenal fistula, Gastrointestinal bleeding, Cystic artery, Gallstone disease, Peptic ulcer Corresponding Author(s) Med Dheker Touati ( [email protected] ) Close Corresponding author: Med Dheker Touati Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2024 Touati MD et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Touati MD, Dziri W, Yousfi R et al. Case Report: Cystic artery peptic erosion: Uncommon cause of massive upper gastrointestinal bleeding. [version 1; peer review: 1 approved] . F1000Research 2024, 13 :874 ( https://doi.org/10.12688/f1000research.149688.1 ) First published: 02 Aug 2024, 13 :874 ( https://doi.org/10.12688/f1000research.149688.1 ) Latest published: 02 Aug 2024, 13 :874 ( https://doi.org/10.12688/f1000research.149688.1 ) Introduction The cholecystoenteric fistula, an abnormal communication between the gallbladder and the gastrointestinal tract, represents a rare complication of cholelithiasis. The symptoms of cholecystoenteric fistula vary, and an accurate diagnosis before surgery is rarely established. It also rarely presents as upper gastrointestinal bleeding. In this context, we present a rare case of cholecystoduodenal fistula that manifested as hypovolemic shock due to massive upper gastrointestinal bleeding, and the origin was identified as the cystic artery. Furthermore, this case reflects the necessary multidisciplinary approach to address the complexity of this condition. This work has been reported in line with the SCARE 2023 criteria. 1 Case presentation This is a case report of a 63-year-old diabetic patient on metformin (850 mg daily) with a history of a left forearm fracture that required surgical intervention, including postoperative intramedullary nailing. The patient received postoperative pain management with non-steroidal anti-inflammatory drugs (550 mg once daily) and a proton pump inhibitor (20mg once daily). He presented to our emergency department with hematemesis persisting for two days prior to admission, along with melena, and no fever. On examination, the patient was hemodynamically unstable with a blood pressure of 70/50 mmHg, a heart rate of 95 bpm, and was afebrile. Rectal examination revealed melena. Laboratory findings showed blood type A+, hemoglobin of 6.5 g/dL, and a prothrombin time of 80%. Renal function was within normal limits. The patient was admitted to the intensive care unit with two peripheral intravenous lines, a urinary catheter, normal saline infusion, and a bolus of omeprazole (80 mg), followed by continuous infusion at a rate of 2 mg/hour. Additionally, he received a transfusion of 2 units of packed red blood cells. After stabilization of the hemodynamic status without the need for catecholamines, a diagnostic esophagogastroduodenoscopy was performed, revealing a large ulcer at the anterior wall of the first part of duodenum with active bleeding, classified as Forrest Ib ( Figure 1 ). Adrenaline (1/1000 dilution) was injected for chemical hemostasis, and two clips were applied to achieve hemostasis. Figure 1. Oesophagogastroduodenoscopy image showing a large Forrest Ib ulcer at the anterior wall of the first part of duodenum. The patient remained stable for 17 hours but subsequently experienced a recurrence of hematemesis and developed tachycardia and hypotension (blood pressure 80/50 mmHg) with a hemoglobin level of 6.1 g/dL.Catecholamines were initiated, and the patient was taken to the operating room for an exploratory laparotomy. A midline incision revealed features of cholecystitis, with the gallbladder neck adherent to the anterior aspect of the duodenal bulb ( Figure 2 ). Figure 2. Per-operative view depicting adhesion between the inflamed gallbladder and the duodenal bulb. The release of the gallbladder from the duodenal bulb revealed the presence of an approximately 1cm ulcer with a visible vessel ( Figures 3 , 4 ). Cholecystectomy was performed along with en bloc resection of the ulcer and gallbladder. The source of bleeding was identified as the cystic artery ( Figure 5 ). The procedure concluded with pyloroplasty and truncal vagotomy. Figure 3. Cholecystoduodenal fistula with visualization of the clip placed during endoscopy. Figure 4. Excision of the duodenal ulcer that remains adherent to the gallbladder (yellow arrow), revealing the ulcer and the vessel responsible for the bleeding (white arrow). Figure 5. Resected specimen. Catheterization of the cystic artery (yellow arrow) through a venous catheter across the ulcer (white arrow). The evolution was favorable with no recurrence of hemorrhage, along with stabilization of hemodynamic status and hemoglobin levels. The patient was discharged on postoperative day 10. Postoperative follow-up was favorable with no recurrence of hemorrhage after 1 year of follow-up. Discussion We present an exceptionally rare case of gastrointestinal bleeding manifested as hematemesis, related to the erosion of the cystic artery caused by a cholecysto-duodenal fistula and an ulcer on the anterior aspect of the bulb. The study is limited by the patient’s postoperative demise, preventing subsequent follow-up. Cholecystoenteric fistula is a rare complication of biliary lithiasis, with autopsy-reported incidences ranging from 0.1% to 0.5%, and an occurrence of 1.2% to 5% among cases undergoing cholecystectomy. 2 This complication is more prevalent in women, typically around the age of 60, 2 and the cholecystoduodenal type is the most frequently observed, followed by cholecystocolonic and cholecystogastric fistulas. 3 Cholecystoenteric fistulas form when the obstructed cystic duct undergoes repetitive inflammation, leading to the adherence of the gallbladder to an adjacent organ. 4 , 5 Approximately 91% to 94% of internally formed biliary fistulas occur spontaneously due to the presence of stones in the biliary tract, with gastric ulcers ranking as the second most common cause. Other potential causes include tumors, biliary abscesses, and echinococcus cysts. 6 Most patients present with general features of gallstone disease, but less commonly, patients may also exhibit cholangitis, severe upper gastrointestinal bleeding, or gallstone ileus. The cholecystoduodenal fistula is rarely associated with gastrointestinal bleeding. Invasion of the cystic artery by a duodenal ulcer can lead to massive bleeding, while a gallstone can cause erosion of the same artery. 2 Severe gastrointestinal bleeding from a cholecystoduodenal fistula is uncommon, as reported by Park et al., who conducted a literature review and identified only 11 case reports. 7 Gallstones were the primary cause, with gastric ulcers as the etiology in only two cases. Endoscopic findings varied, ranging from ulcers to fistulous openings and bleeding of unknown origin. Although endoscopic hemostasis was attempted in four cases, surgical intervention was necessary in all cases, consistent with our case report. The rarity of this condition, despite the high incidence of cholecystitis, could be explained by the more frequent occurrence of cystic artery thrombosis due to nearby inflammation. 8 Bleeding from the biliary tract typically occurs into the duodenum, leading to hematemesis and/or melena in patients. 9 In cases of upper gastrointestinal bleeding with inconclusive endoscopy results, consideration should be given to a cholecystoduodenal fistula with a bleeding marginal ulcer. 9 In a hemodynamically stable patient, a CT scan is required to establish the diagnosis. Endoscopic ultrasound can detect clots in the cystic duct and the gallbladder lumen, indicating potential bleeding from the gallbladder. A definitive diagnosis is often achieved through selective hepatic angiography, which can reveal a pseudoaneurysm or active bleeding from a nondilated cystic artery. This diagnostic method is particularly valuable because it allows for subsequent selective embolization. 10 Angioembolization serves as an alternative treatment in some centers for identifying and potentially stopping active bleeding from a fistula that cannot be managed with endoscopic hemostasis. If angioembolization is performed, it should be followed promptly by surgical intervention. 11 This is essential as the clinical presentation of bleeding caused by gallstones might indicate a more complex gallbladder condition than initially suspected. 12 Cholecystoduodenal fistula leading to severe upper gastrointestinal bleeding is exceedingly rare. 9 Most case reports indicate that the bleeding source is typically the erosion of the cystic artery, either by a duodenal ulcer or gallstones. Managing bleeding cholecystoduodenal fistulas usually requires surgical resection of the fistula and repair of the duodenal perforation due to significant bleeding from the cystic artery, which is unlikely to be resolved by conservative methods. In our case, despite the use of diluted adrenaline injections and the placement of hemostatic clips, the patient continued to experience active bleeding. 6 While laparoscopic methods are often employed due to advanced surgical techniques, open operations are preferred in cases involving anatomical distortion and severe inflammation. Conclusion We present a unique case of massive bleeding from the cystic artery eroded by a duodenal ulcer through a concurrent cholecystoduodenal fistula. Given the rarity of cholecystoduodenal fistula as a cause of massive gastrointestinal bleeding, it is imperative for clinicians to be attentive to certain signs that can facilitate the differential diagnosis. A thorough consideration of medical history remains essential, as a history of gallstone disease can guide the diagnosis. Ethical approval Ethical approval for case reports is not necessary. Consent Written informed consent to publish this case and associated images was obtained from the patient. Author contributions Wassim dziri: Conceptualization, Writing – Original Draft Preparation Med Dheker TOUATI: Writing – Original Draft Preparation Nadhem khlifi: Writing – Original Draft Preparation Rahma yousfi: Conceptualization, Writing – Original Draft Preparation Sana Landolsi: Conceptualization, Writing – Review & Editing Faouzi CHEBBI: Supervision, Writing – Review & Editing Data availability statement All data underlying the results are available as part of the article and no additional source data are required. References 1. Sohrabi C, Mathew G, Maria N, et al. : The SCARE 2023 guideline: updating consensus Surgical CAse REport (SCARE) guidelines. Int. J. Surg. 1 mai 2023; 109 (5): 1136–1140. PubMed Abstract | Publisher Full Text | Free Full Text 2. Lee SB, Ryu KH, Ryu JK, et al. : Acute acalculous cholecystitis associated with cholecystoduodenal fistula and duodenal bleeding. A case report. Korean J. Intern. Med. juin 2003; 18 (2): 109–114. PubMed Abstract | Publisher Full Text | Free Full Text 3. Inal M, Oguz M, Aksungur E, et al. : Biliary-enteric fistulas: report of five cases and review of the literature. Eur. Radiol. 1999; 9 (6): 1145–1151. PubMed Abstract 4. Glaysher MA, Cruttenden-Wood D, Szentpali K: A rare cause of upper gastrointestinal haemorrhage: Ruptured cystic artery pseudoaneurysm with concurrent cholecystojejunal fistula. Int. J. Surg. Case Rep. 1 janv 2014; 5 (1): 1–4. PubMed Abstract | Publisher Full Text | Free Full Text 5. Chadha M, Ahuja C: Visceral Artery Aneurysms: Diagnosis and Percutaneous Management. Semin. Intervent. Radiol. sept 2009; 26 (03): 196–206. PubMed Abstract | Publisher Full Text | Free Full Text 6. Vadioaloo DK, Loo GH, Leow VM, et al. : Massive upper gastrointestinal bleeding: a rare complication of cholecystoduodenal fistula. BMJ Case Rep. 1 mai 2019; 12 (5): e228654. PubMed Abstract | Publisher Full Text | Free Full Text 7. Park JM, Kang CD, Kim JH, et al. : Cholecystoduodenal fistula presenting with upper gastrointestinal bleeding: A case report. World J. Clin. Cases. 16 janv 2021; 9 (2): 410–415. PubMed Abstract | Publisher Full Text | Free Full Text 8. Wu TC, Liu TJ, Ho YJ: Pseudoaneurysm of the cystic artery with upper gastrointestinal hemorrhage. Case report. Acta Chir. Scand. févr 1988; 154 (2): 151–152. PubMed Abstract 9. Vyacheslav Bard YF: An Unusual Presentation of Cholecystoduodenal Fistula: Massive Upper Gastrointestinal Bleeding. J. Gastrointest. Dig. Syst. 2014 [cité 4 févr 2024]; 05 (04). Publisher Full Text Reference Source 10. Contini S, Uccelli M, Sassatelli R, et al. : Gallbladder ulcer eroding the cystic artery: a rare cause of hemobilia. Am. J. Surg. août 2009; 198 (2): e17–e19. PubMed Abstract | Publisher Full Text 11. Delgadillo X, Berney T, de Perrot M , et al. : Successful Treatment of a Pseudoaneurysm of the Cystic Artery with Microcoil Embolization. J. Vasc. Interv. Radiol. 1 juin 1999; 10 (6): 789–792. PubMed Abstract | Publisher Full Text 12. Ben-Ishay O, Farraj M, Shmulevsky P, et al. : Gallbladder ulcer erosion into the cystic artery: a rare cause ofupper gastro-intestinal bleeding Case report. World J. Emerg. Surg. 12 mars 2010; 5 (1): 8. PubMed Abstract | Publisher Full Text | Free Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 02 Aug 2024 ADD YOUR COMMENT Comment Author details Author details 1 Department of General Surgery, Mahmoud El Matri Hospital, Ariana, Tunisia Med Dheker Touati Roles: Writing – Original Draft Preparation Wassim Dziri Roles: Conceptualization, Writing – Original Draft Preparation Rahma Yousfi Roles: Conceptualization, Writing – Original Draft Preparation Nadhem Khlifi Roles: Writing – Original Draft Preparation Sana Landolsi Roles: Conceptualization, Writing – Review & Editing Faouzi Chebbi Roles: Supervision, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 02 Aug 2024, 13:874 https://doi.org/10.12688/f1000research.149688.1 Copyright © 2024 Touati MD et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Touati MD, Dziri W, Yousfi R et al. Case Report: Cystic artery peptic erosion: Uncommon cause of massive upper gastrointestinal bleeding. [version 1; peer review: 1 approved] . F1000Research 2024, 13 :874 ( https://doi.org/10.12688/f1000research.149688.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 02 Aug 2024 Views 0 Cite How to cite this report: Emuobor O. Reviewer Report For: Case Report: Cystic artery peptic erosion: Uncommon cause of massive upper gastrointestinal bleeding. [version 1; peer review: 1 approved] . F1000Research 2024, 13 :874 ( https://doi.org/10.5256/f1000research.164178.r315848 ) The direct URL for this report is: https://f1000research.com/articles/13-874/v1#referee-response-315848 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 11 Sep 2024 Odeghe Emuobor , Medicine, Lagos University Teaching Hospital, Surulere, Lagos, Nigeria Approved VIEWS 0 https://doi.org/10.5256/f1000research.164178.r315848 The paper describes a rare but important cause of upper gastrointestinal bleeding. Please, the authors will do well to clarify the following: 1. The names of the NSAID and PPI given postoperatively; only the doses are ... Continue reading READ ALL The paper describes a rare but important cause of upper gastrointestinal bleeding. Please, the authors will do well to clarify the following: 1. The names of the NSAID and PPI given postoperatively; only the doses are mentioned. 2. At what point did the patient pass away? While the authors mention that there was no recurrence of bleeding at 1 year of follow up, they also mention the patient's demise as a limitation. Is the background of the case’s history and progression described in sufficient detail? Partly Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Gastroenterology and Hepatology. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Emuobor O. Reviewer Report For: Case Report: Cystic artery peptic erosion: Uncommon cause of massive upper gastrointestinal bleeding. [version 1; peer review: 1 approved] . F1000Research 2024, 13 :874 ( https://doi.org/10.5256/f1000research.164178.r315848 ) The direct URL for this report is: https://f1000research.com/articles/13-874/v1#referee-response-315848 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 02 Aug 2024 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 Version 1 02 Aug 24 read Odeghe Emuobor , Lagos University Teaching Hospital, Surulere, Nigeria Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Emuobor O. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 11 Sep 2024 | for Version 1 Odeghe Emuobor , Medicine, Lagos University Teaching Hospital, Surulere, Lagos, Nigeria 0 Views copyright © 2024 Emuobor O. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The paper describes a rare but important cause of upper gastrointestinal bleeding. Please, the authors will do well to clarify the following: 1. The names of the NSAID and PPI given postoperatively; only the doses are mentioned. 2. At what point did the patient pass away? While the authors mention that there was no recurrence of bleeding at 1 year of follow up, they also mention the patient's demise as a limitation. Is the background of the case’s history and progression described in sufficient detail? Partly Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Gastroenterology and Hepatology. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Emuobor O. Peer Review Report For: Case Report: Cystic artery peptic erosion: Uncommon cause of massive upper gastrointestinal bleeding. [version 1; peer review: 1 approved] . F1000Research 2024, 13 :874 ( https://doi.org/10.5256/f1000research.164178.r315848) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-874/v1#referee-response-315848 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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Register $(document).ready(function () { signIn.createSignInAsRow($("#sign-in-form-gfb-popup")); $(".target-field").each(function () { var uris = $(this).val().split("/"); if (uris.pop() === "login") { $(this).val(uris.toString().replace(",","/")); } }); });