Autistic enterocolitis

"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.Is it a histopathological entity?
*cite journal |author=MacDonald TT, Domizio P |title=Autistic enterocolitis; is it a histopathological entity? |journal=Histopathology |volume=50 |issue=3 |pages=371–9 |year=2007 |doi=10.1111/j.1365-2559.2007.02606.x |pmid=17257133
*cite journal |author=Wakefield AJ |title=Autistic enterocolitis; is it a histopathological entity?—reply |journal=Histopathology |volume=50 |issue=3 |pages=380–4 |year=2007 |doi=10.1111/j.1365-2559.2007.02607.x |pmid=17257133
*cite journal |author=Dhillon A |title=Autistic enterocolitis; is it a histopathological entity? |journal=Histopathology |volume=50 |issue=6 |pages=794 |year=2007 |doi=10.1111/j.1365-2559.2007.02668.x |pmid=17376170
*cite journal |author=MacDonald TT, Domizio P |title=Autistic enterocolitis; is it a histopathological entity? |journal=Histopathology |volume=51 |issue=4 |pages=552–3 |year=2007 |doi=10.1111/j.1365-2559.2007.02805.x |pmid=17880534]

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. [cite journal |author=Taylor B, Miller E, Lingam R, Andrews N, Simmons A, Stowe J |title=Measles, mumps, and rubella vaccination and bowel problems or developmental regression in children with autism: population study |journal=BMJ |volume=324 |issue=7334 |pages=393–6 |year=2002 |pmid=11850369|url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=11850369 |doi=10.1136/bmj.324.7334.393]

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. [cite journal |author=Black C, Kaye JA, Jick H |title=Relation of childhood gastrointestinal disorders to autism: nested case-control study using data from the UK General Practice Research Database |journal=BMJ |volume=325 |issue=7361 |pages=419–21 |year=2002 |pmid=12193358 |doi=|url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12193358] Thus, it is not generally accepted that the types of colitis found in autism are unique to autism. [cite web|url=http://www.bbc.co.uk/sn/tvradio/programmes/horizon/mmr_prog_summary.shtml|title=Does the MMR Jab Cause Autism?|publisher=bbc.co.uk|accessdate=2007-11-25]

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. [cite journal |author= Wakefield A, Murch S, Anthony A "et al." |title= Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children |journal=Lancet |volume=351 |issue=9103 |pages=637–41 |year=1998 |doi=10.1016/S0140-6736(97)11096-0 |pmid=9500320 |url=http://briandeer.com/mmr/lancet-paper.htm |accessdate=2007-09-05]

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. [cite web|url= http://briandeer.com/wakefield/ileal-hyperplasia.htm|title=Wakefield MMR-autism sign was recognized for years: as benign finding in children|publisher=Brian Deer|accessdate=2007-11-25] 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: [cite web|url=http://briandeer.com/mmr/lancet-summary.htm|title=The MMR-autism scare - our story so far|publisher=Brian Deer|accessdate=2007-11-23]
* 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.

upposed 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. [cite journal | author = Thjodleifsson B, Davídsdóttir K, Agnarsson U, Sigthórsson G, Kjeld M, Bjarnason I | title = Inflammation and Inflammatory Bowel Disease: Effect of Pentavac and measles-mumps-rubella (MMR) vaccination on the intestine. | journal = Gut | volume = 51 | issue = 6 | pages = 816–7 | year = 2002 | month = Dec | pmid = 12427783] Researchers have identified a high incidence of bowel symptoms in autistic children before the MMR vaccine was licensed. [cite web|url=http://briandeer.com/wakefield/coleman-child.htm|title=Study found many autistic children with bowel problems before MMR was licensed|publisher=Brian Deer|accessdate=2007-11-24] 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.

"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 administraiton 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".cite journal |author=Murch SH, Anthony A, Casson DH, "et al" |title=Retraction of an interpretation |journal=Lancet |volume=363 |issue=9411 |pages=750 |year=2004 |pmid=15016483 |doi=10.1016/S0140-6736(04)15715-2] 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. [cite web|url=http://www.newscientist.com/article.ns?id=dn4743|title=Controversial MMR and autism study retracted|date=04 March 2004|publisher=NewScientist.com|author=McKee, Maggie|accessdate=2007-11-25] However, it was subsequently revealed by "The Sunday Times" of London that Wakefield had personally been paid more than £400,000.cite news| title=MMR Doctor given legal aid thousands|work=The Sunday Times |date=December 31 2006|author=Deer, Brian|url=http://briandeer.com/mmr/st-dec-2006.htm|accessdate=2007-11-25]

Wakefield, who did not sign the retraction, currently face disciplinary charges before the General Medical Council over the conduct of this research. [cite news|author=Deer, Brian|title = MMR Scare Doctor Faces List of Charges|publisher=The Sunday Times (London)|date= 2005-09-11|url = http://briandeer.com/wakefield/gmc-alleges.htm|format=Reprint|accessdate=2007-08-10 ] 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." [http://www.cochrane.org/press/MMR_final.pdf]

References

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External links

* [http://www.autism-biomed.org/mmr-rev.htm Autism-BioMed.org] - 'MMR vaccine and autism, revisited' (commentary)', Ronald J. Kallen, MD, Autism Biomedical Information Network (May 31, 2000)
* [http://www.melaniephillips.com/articles/archives/001468.html MelaniePhillips.com] - 'MMR: the unanswered questions', Melanie Phillips, "Daily Mail", (October 31, 2005)
* [http://education.guardian.co.uk/higher/comment/story/0,,1606768,00.html "The MMR skeptic who just doesn't understand science"] , Ben Goldacre, The Guardian (November 2, 2005)
* [http://www.melaniephillips.com/articles/archives/001476.html MelaniePhillips.com] - 'Evidence-based' ignorance over MMR, Melanie Phillips, "Daily Mail", (November 08, 2005)
* [http://briandeer.com/mmr/lancet-summary.htm BrianDeer.com] - 'The MMR-autism scare - Summary of a Scandal', Brian Deer (2005)
* [http://www.cdc.gov/nip/vacsafe/concerns/autism/ibd.htm CDC.gov] - 'FAQs about measles vaccine and inflammatory bowel disease', Centers for Disease Control
* [http://www.cochrane.org/press/MMR_final.pdf Cochrane.org] - 'The Cochrane Library publishes the most thorough survey of MMR vaccination data which strongly supports its use', Cochrane Library (October 19, 2005)
* [http://www.medadnews.com/News/Index.cfm?articleid=305163 MedAdNews.com] - 'Impact of Gastrointestinal Dysfunction in Autistic Children'. PRNewswire (January 11, 2006)
* [http://www.rxpgnews.com/research/infectiousdiseases/article_2661.shtml RxPGNews.com] - 'MMR vaccine - An End to the Controversy' (October 19, 2005)