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"Autistic enterocolitis" is a controversial term first used by British gastroenterologist Andrew Wakefield to describe a number of common clinical symptoms and signs which he contends are distinctive to autism. The existence of autistic enterocolitis is controversial, as the methodology of Wakefield's studies has been criticized and his results have not been replicated by other groups.^[1] Most of Wakefield's coauthors later retracted the conclusions of the original paper proposing the hypothesis,^[2] and Wakefield has been accused of manipulating patient data and misreporting results in the paper.^[3]

Background

Until the 1970s, autism was rarely accepted to be a distinctive diagnosis, but, following changes to the Diagnostic and Statistical Manual of the American Psychiatric Association it is diagnosed much more often. How much of this increase is due to greater diagnostic vigilance by doctors, changes in diagnostic categories, or an actual increase in prevalence, remains unclear. Late-onset autism cases are estimated at 25% and reported by sources including the British Medical Journal as not having changed in recent years.^[4]

Despite others describing common bowel features, there have been no peer reviewed studies yet published, as of 2006, corroborating the existence of autistic enterocolitis; other studies have explicitly denied its existence.^[5] Thus, it is not generally accepted that the types of colitis found in autism are unique to autism.^[6]

However, in spite of the studies suggesting there is no evidence of enterocolitis causing autism, media reports have claimed that it is possible the relation exists:

Lancet study

When Wakefield and his colleagues first reported in 1998 a possible association between autistic regression, IBD, and MMR vaccines in the Lancet, they evaluated a dozen children with pervasive developmental disorders, apparent developmental regression, and intestinal symptoms, referred to the Royal Free Hospital.^[7]

According to parents, onset of behavioral symptoms was linked to recent (within two weeks) immunization with MMR vaccine in eight of the children diagnosed with developmental disorders. The most consistent report was lymphoid nodular hyperplasia of the terminal ileum in nine of the children. This feature has also been reported to be very common in non-autistic children.^[8] A variety of colonic and rectal mucosal features was reported in eight cases. Biopsies of the ileum was reported to have shown reactive lymphoid follicular hyperplasia in seven. Biopsies of the colon was reported to have shown a diffuse mononuclear cell infiltrate in six.

Wakefield and his colleagues say they have described features of regressive autism with bowel disorders, or what Wakefield would later call autistic enterocolitis, although these findings have been questioned, with claims that the association of features is substantially an artifact of preselection of vaccinated children with both developmental disorders and bowel symptoms for a UK lawsuit:^[9]

• Most of the children were reported to have swelling of the lymphoid tissue lining the intestines, particularly near where the small and large intestines meet, and inflammation of the large intestine, associated with constipation, diarrhea and, in some cases, pain.
• In some affected children, impaired cellular immunity to common recall antigens, with low numbers of circulating white blood cells were reported.
• A specific measles protein signal is claimed to have been detected in inflamed lymphoid tissue.
• In some cases, loss of speech and language, bowel disturbances, self-injury, and a self-limited diet, associated with cravings for particular foods.
• Allergies, food intolerances are also reported in some children.

Supposed link to MMR vaccinations

Wakefield has hypothesized that autistic enterocolitis is an emergent IBD phenotype that follows from exposure to the vaccinations given to children during a period when their immune systems are rapidly developing. Other research, however, rejects this hypothesis, and other groups have not reproduced Wakefield's findings.^[10] Researchers have identified a high incidence of bowel symptoms in autistic children before the MMR vaccine was licensed.^[11] It was also revealed that, prior to the publication of Wakefield's studies alleging a connection between the MMR vaccine and autistic enterocolitis, he had received over £400,000 from lawyers attempting to sue vaccine manufacturers. This conflict of interest, which Wakefield denies, has led many to criticize Wakefield and his results. The British General Medical Council has launched an inquiry into possible dishonesty by Wakefield regarding his research.^[12]

"Retraction of an interpretation"

The Lancet paper has been widely cited as an impetus for concerns regarding the MMR vaccine being a cause of Autism. Wakefield gave interviews after the publication of the paper, including on 60 Minutes where he raised concerns regarding administration of the MMR vaccine. In the Lancet paper, Wakefield and his co-authors said on the issue:

"We did not prove an association between measles, mumps, and rubella vaccine and the syndrome described. Virological studies are underway that may help to resolve this issue"

In 2004, 10 of the 13 authors issued a statement in the Lancet entitled "Retraction of an interpretation".^[2] In this, the authors retracted the conclusion section of the paper, formally known in the Lancet and in many biomedical journals, as the "interpretation". The section of the paper retracted said:

"Interpretation. We identified associated gastrointestinal disease and developmental regression in a group of previously normal children, which was generally associated in time with possible environmental triggers."

In the retraction, issued in March 2004, they said:

"We wish to make it clear that in this paper no causal link was established between MMR vaccine and autism as the data were insufficient. However, the possibility of such a link was raised and consequent events have had major implications for public health. In view of this, we consider now is the appropriate time that we should together formally retract the interpretation placed upon these findings in the paper, according to precedent."

The authors also said:

"The main thrust of this paper was the first description of an unexpected intestinal lesion in the children reported. Further evidence has been forthcoming in studies from the Royal Free Centre for Paediatric Gastroenterology and other groups to support and extend these findings. While much uncertainty remains about the nature of these changes, we believe it important that such work continues, as autistic children can potentially be helped by recognition and treatment of gastrointestinal problems."

Just before the retraction, criticism arose over the fact that the Royal Free Hospital had received £55 000,00 in August 1996 from lawyers preparing to sue MMR manufacturers for support of Dr. Wakefield's research. Wakefield asserted that the donation was to fund a second clinical study; some of the children involved were subjects in both studies.^[13] However, it was subsequently revealed by The Sunday Times of London that Wakefield had personally been paid more than £400,000.^[12]

Wakefield, who did not sign the retraction, currently faces disciplinary charges before the General Medical Council over the conduct of this research.^[14] In February 2009 The Sunday Times reported that Wakefield had manipulated patient data and misreported results in his 1998 paper, creating the appearance of a link with autism.^[3]

In October 2005, the Cochrane Library published its analysis of 31 "high quality" medical studies which concluded no link could be found between the MMR vaccine and bowel disease, autism or other pervasive developmental disorders. To increase the rigor of the meta-analysis, the criteria of the meta-analysis excluded smaller studies and studies that had the potential for bias. Wakefield's work was specifically excluded in the meta-analysis due to small sample size. With regard to the vaccine, Cochrane said that its survey of research "strongly supports its use".^[15][16]

U.S. Court of Federal Claims

On February 12, 2009, three Special Masters of the United States Court of Federal Claims rendered three opinions^[17] in three "test cases" that were proceeding in that court, each of which addressed causation issues relating to MMR vaccine and autism spectrum disorders (ASDs). The opinions were critical of Dr. Arthur Krigsman^[18] and his testimony about autistic enterocolitis, which the court described as a "new form of gastrointestinal [GI] disorder." Typical of their criticism was the following passage found at page 199 of the opinion in the Snyder case^[19]: "Doctor Krigsman was qualified to testify about gastroenterology [but his] qualifications to establish the validity of a new form of gastrointestinal disorder, unrecognized by other authorities in the field, were ... sadly lacking." The court noted that the "medical textbooks" do not recognize autistic enterocolitis, but did not opine as to whether the rapidity with which ASD cases have increased in recent years may be a factor in the lagging recogniztion of a GI-ASD connection. At page 27, the same opinion stated that "Dr. Krigsman’s testimony about autistic enterocolitis as a diagnostic entity was speculative," but all three opinions also detail facts indicating that Mount Sinai hospital actively thwarted Krigsman's attempts to conduct further research on that diagnostic entity. A letter to the editor^[20] published in the Austin American-Statesman on February 25, 2009, was critical of the Special Masters' treatment of Dr. Krigsman's work in exploring the GI symptoms associated with ASD, opining that such work "is important, and it is unfortunate that the comments of the special masters have undermined his efforts."

References

• Fombonne E, Chakrabarti S (October 2001). "No evidence for a new variant of measles-mumps-rubella-induced autism". Pediatrics 108 (4): E58. doi:10.1542/peds.108.4.e58. PMID 11581466. http://pediatrics.aappublications.org/cgi/content/full/108/4/e58.  
• Wakefield A, Anthony A, Murch S, Thomson M, Montgomery S, Davies S, O'Leary J, Berelowitz M, Walker-Smith J (September 2000). "Enterocolitis in children with developmental disorders". Am J Gastroenterol 95 (9): 2285–95. doi:10.1111/j.1572-0241.2000.03248.x. PMID 11007230.  

External links

Pervasive Developmental Disorders portal

• Autism-BioMed.org - 'MMR vaccine and autism, revisited' (commentary)', Ronald J. Kallen, MD, Autism Biomedical Information Network (May 31, 2000)
• MelaniePhillips.com - 'MMR: the unanswered questions', Melanie Phillips, Daily Mail, (October 31, 2005)
• "The MMR skeptic who just doesn't understand science", Ben Goldacre, The Guardian (November 2, 2005)
• MelaniePhillips.com - 'Evidence-based' ignorance over MMR, Melanie Phillips, Daily Mail, (November 8, 2005)
• BrianDeer.com - 'The MMR-autism scare - Summary of a Scandal', Brian Deer (2005)
• CDC.gov - 'FAQs about measles vaccine and inflammatory bowel disease', Centers for Disease Control
• Cochrane.org - 'The Cochrane Library publishes the most thorough survey of MMR vaccination data which strongly supports its use', Cochrane Library (October 19, 2005)
• MedAdNews.com - 'Impact of Gastrointestinal Dysfunction in Autistic Children'. PRNewswire (January 11, 2006)
• RxPGNews.com - 'MMR vaccine - An End to the Controversy' (October 19, 2005)