Monday, February 21, 2011

Krigsman 2010 and Constipation

Krigsman’s 2010 paper
Krigsman’s 2010 paper Clinical presentation and Histologic Findings at Ileocolonoscopy in children with Autistic spectrum Disorder and chronic Gastrointestinal symptom reported on “143 consecutive patients with ASD/developmental disorder, undergoing ileocolonoscopy and biopsy as part of routine investigations of persistent GI symptoms.”

Considering that the paper doesn’t even mention the phrases inflammatory bowel disease, Crohn’s or Ulcerative Colitis, it seems likely that Krigsman did in New York State with 143 chldren (and elsewhere to total 275?) what Wakefield, Walker-Smith and others did with many children at the Royal Free hospital in London --- perform colonoscopies that were not clinically indicated.

Krigsman. a gastroenterologist,  is a follower of Wakefield’s discredited theory. He worked with Wakefield at Thoughtful House in Austin, Texas until February 2010, when both he and Wakefield left.  Until  February 2010, he and Wakefield and Professor Stephen Walker were on the editorial board of Autism Insights where Krigsman’s paper was published. Krigsman and Lenox Hill hospital, where the colonoscopies were performed, parted company over concerns that these colonoscopies were done as an unapproved research project. For details read results from this search query krigsman

Krigsman, as an acolyte of Wakefield, believed that persistent measles virus from the MMR vaccine caused autism.  So he took biopsiers to Professor Stephen Walker at Wake Forest University.  Walker reported preliminary results in 2006. in a poster presentation at IMFAR in Montreal  S. Walker, K. Hepner, J. Segal, A. Krigsman “Persistent Ileal Measles Virus in a Large Cohort of Regressive Autistic Children with Ileocolitis and Lymphonodular Hyperplasia: Revisitation of an Earlier Study”
According to the results of Dr. Walker’s study, 82 children with regressive autism and bowel disease, 70 have so far proved positive for the measles virus. The team will be examining a total of 275 children with regressive autism and bowel disease.
As the title indicates, this was the study that was going to prove Wakefield right and the world wrong. Except….it is now 2011 and Walker hasn’t published his results –most likely because he has negative results.  Note that the summary is wrong.  The children in the study didn’t have bowel disease. Rather as the title states they had Ileocolitis (whatever that is) and Lymphonodular Hyperplasia (recall that Wakefield’s 1998 paper was titled Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children.

Professor Booth and Constipation

I've had Crohn's disease for decades. More recently, I've added a condition which can cause constipation. So when I was reading the GMC transcripts and Professor Booth's discussion of colonoscopy and spurious diarrhea, it really hit home.

Simply put, a colonoscopy is done to diagnose Inflammatory Bowel Disease.  If you don't have reason to believe you will find inflammatory bowel disease, you don't do a colonoscopy --- it isn't clinically indicated.   Using a criminal standard of proof page 2 , the UK medical licensing board found that 
In respect of the clinical care of the children, Professor Walker-Smith assessed nine of the Lancet children in the outpatients’ clinic, prior to admission and all eleven children were admitted to hospital under his clinical care. The public is entitled to expect that patients entrusted to the clinical care of a doctor will be treated in accordance with their best clinical interests.
 With regard to Child 2, 1, 3, 9, 5, 12 and 8, Professor Walker-Smith caused all seven of them to undergo colonoscopies that were not clinically indicated.   Walker-Smith sanctions determination
From the Transcripts  (available online through here)
Q [Ms. Smith for the GMC]         Could we go to page 40 for the moment? That is the offices within medical societies. You [Professor Booth] have been President of the British Society of Paediatric Gastroenterology and Nutrition, Chairman of the Paediatric Committee of the British Society of Gastroenterology and Council Member of the Paediatric Research Society, amongst others.
A [Professor Booth]Yes.    
Day 40 page 2 of transcripts
Q With regard to your own clinical practice, do you regularly see children as patients?
A Yes, I do.
Q Does that include, amongst of course many other children, children with autism?
A Yes.
Q Do you yourself personally carry out colonoscopies?
A Yes, I do.
Q When did you last do a colonoscopy?
A Last week.
Q Do you have out-patients clinics every week with children?
A Yes.               40/3
Professor Booth referred to a 1992 textbook.
Q Turning on to page 23, the indications for the procedure, at the bottom right-hand column:
“The symptoms that lead to a request for proctocolonoscopy in children may be summed up as follows:
1.recurring rectal bleeding with no anal lesions.
2. signs indicative of colitis; that is mucousy and/or blood diarrhoea, abdominal pain which may or may not be combined with emaciation, and a febrile state.”
That is in 1992. Would you agree that in broad terms those are the indications?
A Yes. They had not really changed. When we published the first description of colonoscopy in children ten years earlier, those were essentially the same indications.
Q Thank you. Is constipation, as a general proposition, ever an indication to undertake a colonoscopy?
A I cannot think of an indication. Expressly, it would be a contra-indication because you would find it hard going to see anything.
Q If there is a problem which involves constipation as a symptom, is it sometimes the case that it is assisted by the preparation for the colonoscopy; in other words, the clearing out of the colon?
A Yes, the preparation for colonoscopy is a very effective treatment for constipation.
Q When you say you cannot think of a situation where constipation would be an indication, do you sometimes have a situation arising where there is an overflow problem?
A Yes, one of the problems sometimes with making the diagnosis of constipation is that it can present with what is loose stools, which parents interpret as diarrhoea. Not surprisingly, often there is abdominal pain because the colon is full of stool and the colonic muscles are trying to empty the colon against an obstruction. In patients who have severe constipation, eventually the colon reaches its capacity for the amount of stool that it is possible to hold and stool starts leaking out from the anus, often uncontrollably. It is called “spurious diarrhoea” and in fact the patient is constipated but the parents come along and say, “My child’s got diarrhoea.”     40/9  40/10
Krigsman knew that his 143 consecutive colonoscopies would be suspected of having been done for research purposes or without the proper indications for a colonoscopy. That’s why there is such a long-winded description of the subjects in the paper that concludes:
Patients refractory to conventional non-invasive management of gastrointestinal symptomotology underwent subsequent diagnostic ileocolonoscopy with
mucosal biopsies. The specific indications for ileocolonoscopy were thus chronic diarrhea, constipation, and abdominal pain, either alone or in combination, that were (a) of unknown etiology, (b) refractory to conventional, noninvasive therapy and (c) significantly impacted quality of life. All colonoscopies were performed in the endoscopy unit of Lenox Hill Hospital, New York.
But when you get down to it, these were very likely kids with bad constipation who had colonoscopies that weren’t clinically indicated as part of an unapproved research project.


  1. I'd like to thank you. I mentioned on facebook today's (Oct 25 2011) CDC recommendation that boys also receive the HPV vaccine. What happened next took me somewhat off guard. Let's just say the conversation began revolving around the autism connection. Well... I did my best, but as a layperson had a hard time keeping up. Found the refutation of Wakefield, but then the paper mentioned here came up. Your blog provided what I needed -- the paper never quite making it to a published (and thus I presume peer-ready?) state, and the connections between its authors and Wakefield. Again, thanks.

    Jon Trott / Chicago

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