|
Arthur Krigsman MD
Mr. Chairman and members of the committee:
This testimony represents the scientific findings of data accumulated
over the past year and a half from autistic children during the course of
standard evaluations of their gastrointestinal symptoms. This testimony
should in no way be taken as anti-vaccine. Children in my pediatric
practice continue to receive all vaccinations in accordance with the
guidelines set forth by the American Academy of Pediatrics. The
observations expressed herein are my own, and do not represent the
opinions of any institution, organization, clinic, or medical practice
with which I may be associated.
My involvement with autistic children began approximately one and a
half years ago. At that time, I was approached by a colleague who was
caring for a large number of autistic patients. He observed that a large
proportion of these patients suffered from chronic, unexplained
gastrointestinal symptoms and that these symptoms were a source of great
anxiety to the parents. I agreed to evaluate them, and my findings are
detailed below. The evaluations undertaken were standard “textbook”
evaluations of children with chronic diarrhea, constipation, and abdominal
pain, uninfluenced by the fact that these children were autistic.
Patient Population
Our experience consists of a total of 43 consecutive children aged 2-10
years of age. Most were referred by private practitioners but many were
self referred after much frustration with their children’s ongoing
discomfort. 42 patients had received a diagnosis of either autistic
disorder or autistic spectrum disorder by a pediatric neurologist or
developmental pediatrician. Many children had received independent
confirmation from a second or even a third pediatric specialist. In no
instance was the diagnosis disputed by a second specialist. The remaining
patient carried a diagnosis of Aspergers syndrome.
The majority of patients had a clear history of developmental
regression. Specifically, these children developed in an entirely normal
fashion for the first 12-18 months. They typically had a vocabulary of
15-25 words, maintained normal eye contact, were playful and interactive,
and were not overly irritable. At some point during this age interval of
12-18 months, they had either a precipitous or gradual decline in all the
above mentioned developmental markers, and this was accompanied by the
appearance of typical autistic behaviors, “stimming”, and bouts of
unexplained irritability. In some patients, verbal stagnation, but not
regression occurred. However, in these patients, clear regression was seen
in the interactive and social skills of the children.
The majority of patients are from the northeastern United States. The
ratio of males to females was 7:1.
Symptomatology
The most common gastrointestinal symptom noted by the parents was
diarrhea. In some children, the diarrhea took the form of a soupy liquid
that occurred 4 to 7 times per day and would frequently leak from the
child’s diaper. However, the majority of parents reported a stool
frequency of 1-3 per day with a consistency of mashed potatoes. The stool
is particularly malodorous, and usually contains pieces of undigested
foods. Irritability is often noted just prior to the bowel movement.
Constipation is another frequent complaint, consisting of bowel
movements every 3-6 days and typically accompanied by great irritability
upon passage of the stool. The consistency of the passed stool was not
overly hard, suggesting that these children are actually withholding stool
and not truly constipated in the strict sense of the term. This
constipation is often accompanied by abdominal distension and flatulence.
Most patients experienced periods of diarrhea alternating with periods of
constipation.
Abdominal pain is another frequent complaint. Most of these children
are poorly communicative, and parents often rely on body language cues in
determining that their child is experiencing abdominal pain. Children
often drop unexpectedly to the floor howling and screaming. This often
lasts for up to half an hour. Many children clutch their abdomen and bend
over. Some assume a fetal position on the bed or floor, and others take
the parents hand and rub their abdomen.
Finally, we have noticed that most regressive autistic children show
poor growth, with the majority falling in the lower 10th %tile weight for
age. Interestingly, there does not seem to be a concomitant percentile
deficit in height for age.
Evaluation
All children underwent initial evaluation of their gastrointestinal
symptoms. This included a thorough history and physical exam, complete
blood count with platelets, erythrocyte sedimentation rate, serum
chemistries, celiac antibody panel with serum IgA, inflammatory bowel
disease serology, and stool examination for ova and parasites, culture,
and occult blood. The patients diet was thoroughly reviewed to assure that
it did not contain excessive nonabsorbed carbohydrates or fruit juices.
Therapeutic alterations in the diet were undertaken, including the removal
of all gluten and casein containing foods. Medications and supplements
were reviewed to assure that they did not contribute to the symptoms.
The evaluation above invariably did not lead to a diagnosis and
patients then underwent colonoscopy. Upper endoscopy was performed only if
pain was a predominant complaint or if celiac disease was strongly
suspected.
Findings
The above images depict the terminal ileum in two patients. They are
representative of the gross endoscopic findings of 90% of these patients
in whom the lymphoid nodules of the terminal ileum were found to be
markedly enlarged. This is in agreement with the previously published
findings of Dr. Wakefield in which a similar proportion of patients were
found to have abnormal lymphonodular hyperplasia of the terminal ileum.
The second significant finding in our series was on histologic
evaluation of the biopsy specimens. The results are summarized below.
% patients with colitis
28/43
65%
% patients with active colitis
22/43
51%
% patients with chronic colitis
17/43
40%
% patients with eosinophilic colitis
3/43
7%
% LNH (macro) of terminal ileum
36/40
90%
% neither active, chronic, nor eosinophilic
15/43
35%
Colitis was determined as per the report of the institutional
pathologist. The interpretation of whether the degree of inflammation
represented true pathologic inflammation versus a normal variant was
subject to the personal experience of the individual pathologist and was
not subjected to a uniform rating system.
The patterns of inflammation were patchy and unpredictable in any given
patient, but overall were noted in all parts of the colon and terminal
ileum. Although the table above lists chronic and active colitis
separately, most patients with colitis had both chronic and active
inflammation. Most patients had at least 3-4 distinct areas of histologic
inflammation, with an equal number of biopsies that were histologically
normal. The intensity of the inflammatory lesions varied as well, with
many being subtle and somewhat focal, and others being more marked and
diffuse. The latter included areas of cryptitis, crypt abscess,
ulcerations, and dense inflammatory infiltration. One patient was found to
have an inflammatory polyp. Most significantly, these findings were
consistent and seen repeatedly amongst the majority of patients.
In regards to the last group of patients in the table above, it should
be noted that although the histology did not reveal pathologic colonic
inflammation, the majority of these patients were found to have a heavy
and diffuse lymphoid hyperplasia of the colon (macroscopic and
microscopic), signifying an activation of the colon’s internal immune
system.
Conclusion
In a series of 43 autistic children, mostly regressive, with chronic
gastrointestinal symptoms, the majority were found to have pathologic
inflammation of the colon and terminal ileum. 90% had pathologic
lymphonodular hyperplasia of the terminal ileum. Moreover, the findings
were similar and consistent from patient to patient within the affected
group.
Questions
1) Does autistic colitis occur equally in regressive vs. non-regressive
autism?
2) Do differences in growth exist between the colitis and non-colitis
group?
3) Do differences in growth exist between the regressive vs.
non-regressive group?
4) In a retrospective analysis of growth, will onset of growth failure
coincide with the onset of regressive behaviors?
|
