Travelers Diarrhea

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Traveler's Diarrhea

24 Tips to Thwart Turista

You've heard all the names: Montezuma's revenge, Delhi belly, Hong Kong dog, Tiki trots, Casablanca crud, Katmandu quickstep. But citizens of Mexico, India, Nepal, Morocco, and other places might call it the New York nasties, because they can get it when they visit the United States. For now, "it" will have to be called turista, a nice name for traveler's diarrhea.

"If you're going to be abroad for any length of time, you'll probably have some episodes of diarrhea," says globe-trotter Stephen Bezruchka, M.D., an emergency physician at Providence Medical Center in Seattle, Washington. "Conceptually, it is totally preventable. In reality, it's rare you don't get an occasional loose movement." In fact, you have up to a 50 percent chance of getting turista, even if you take the recommended precautions.

The most common cause is the Escherichia coli bacteria. This widespread little organism normally resides in your intestines and performs a role in digestion. But foreign versions—and to a foreigner, the American version is foreign—of E. coli can give you diarrhea by producing a toxin that prevents your intestines from absorbing the water you ingest in the form of fluid and food.

So, as the toxin prevents the absorption of water, "you have all this extra water in there and it's got to come out," Dr. Bezruchka says. "The toxin doesn't get absorbed. You don't usually feel sick, but you might feel you have to pass some gas. Only it isn't gas at all."

Shigella and salmonella bacteria can also produce turista, while a smaller number of cases are caused by rotavirus and the giardia parasite. Changes in diet, fatigue, jet lag, and altitude sickness have been blamed, but without sufficient proof, and up to 50 percent of all turista cases are unexplained.

Thankfully, says Dr. Bezruchka, "diarrhea is a self-limiting disease. The human body has been around for at least 40,000 years, and it's built to take care of most problems it's going to encounter."

The way it takes care of E. coli is to purge the intestines. For one to five days, you'll have numerous runny stools. You may feel nauseated, or have cramps and even a slight fever, but often the only symptom will be the diarrhea itself. And there are ways to help your body fight it, to stop it in its tracks, and to lessen your chances of getting it. Here's how.

Drink water, water anywhere. When you have turista, your stools are mostly water. So why would the most important treatment be to drink plenty of the right fluids? Because dehydration—the loss of water and electrolytes—can kill. Diarrhea kills hundreds of thousands of children every year, often because their parents believe that giving them fluids only makes the diarrhea worse.

So rehydrating yourself when you have turista is not like bringing coals to Newcastle. "A lot of what you take in will be pumped right back out the other end," says Thomas Gossel, Ph.D., a professor of pharmacology and toxicology and chairman of the Department of Pharmacology and Biomedical Sciences at Ohio Northern University. "But you'll reach a point where you stabilize and begin retaining it. If you didn't replace any fluids at all, you could become dehydrated in a day."

The most basic way to rehydrate is to drink water, "if that's all you have around," Dr. Bezruchka says. "If you can't purify the water, drink it anyway. If you're so dehydrated that you get dizzy when you stand up, it's better to replace the fluids than worry about the purity."

How to Be a Nonturista Sometimes no matter what you do, you'll still wind up being an unwilling host to a foreign turista. Yet there are ways to minimize your chances. Avoid uncooked vegetables, especially salads, fruits you can't peel, undercooked meat, raw shellfish, ice cubes, and drinks made from impure water (the alcohol in drinks won't kill the turista bug). Try to make sure the dishes and silverware you use have been cleaned in purified water. Drink only water that has been carbonated and sealed in bottles or cans. Clean the part of the container that touches your mouth and purified water. Boiling water for 3 to 5 minutes purifies it, as does iodine liquid or tablets. Drink acidic drinks like colas and orange juice when possible. They help keep down the E. coli count, the bacteria most responsible for digestive distress. Drink acidophilus milk or eat yogurt before your trip. The bacterial colonies established in your digestive system before your trip and maintained during it, reduce the chance of a turista invasion.

Use the ORS solution. Another, even better way to rehydration is the so-called oral rehydration solution, or ORS, a 1960s advance over intravenous rehydration. An ORS is a drink basically containing sugar and salt, substances that help replace important electrolytes that are lost through diarrhea. They also help your intestines absorb water better. The ORS, in fact, is so beneficial that it is saving thousands of lives in the Third World.

Over-the-counter rehydration solutions are readily available in the United States, so you can buy and take them with you. Some of the name brands are Gastrolyte, Pedialyte, and Rehydralyte. Some are powders, some liquids. Each has a slightly different formula. "There isn't a whole lot of difference between them," Dr. Gossel says.

If you don't want to cart along the extra baggage, you can still get an ORS fix. Here's what you can reach for when you're overseas.

MEDICAL ALERT Be Cautious of Infection Although most cases of turista are self-limiting, some symptoms indicate the need for medical attention. Red or black stools can be a sign of bleeding or a parasitic infection, while white or pale stools can signify liver disease. Fever can suggest a serious infection. If you have blood in the stool or a fever, says Stephen Bezruchka, M.D., and can't get to a doctor quickly, it's advisable to take the antibiotic TMP/SMZ (found overseas over-the-counter) until you can get medical help. Abdominal bloating, vomiting, and pain can indicate colitis, an intestinal obstruction, or appendicitis. Vomiting means you won't be able to retain your rehydration solutions. If you have any of these symptoms, do not take anything to stop the diarrhea, caution doctors.

The USPHS cocktail. This is the U.S. Public Health Service recipe. In one glass, put 8 ounces of fruit juice; 1/2 teaspoon of honey, corn syrup, or sugar; and a pinch of salt. In another glass, put 8 ounces of purified water and 1/4 teaspoon of baking soda. Drink a couple of swallows alternately from each glass until finished.

The WHO combo. "Most underdeveloped countries now are marketing packets with the World Health Organization formula," Dr. Bezruchka reports. The only problem is that they can be very expensive. But you can make your own if you happen to have access to a metric scale. Or you can call in the help of a pharmacist. Here's the formula: glucose, 20 grams; salt, 3.5 grams; baking soda, 2.5 grams; and potassium chloride, 20 grams. Just add to a quart or liter of purified water and drink.

"If your only alternative is buying a packet, you'll have to find out what the local name is," he says. "It's available over-the-counter in drugstores, medical halls, and pharmacies around the world."

The Alternate Route A Survivor's Survival Guide Okay, you're out in the boonies. Your Pepto-Bismol, Metamucil, antibiotics, yogurt tablets, and loperamide washed away in the rapids, which are running almost as fast as your bowels. Now what? We asked SFC Thomas Squier, an instructor in survival training for the U.S. Army Special Forces at Fort Bragg, North Carolina, what he tells his survival training students. He says he's tried the following and they work—but you may only want to use them as his men do—as a last resort. Clay. "We teach them to eat clay," Sgt. Squier says. "Many commercial antidiarrheal medications, like Kaopectate, contain kaolin, which is a type of clay often found on riverbanks. Ash. "We also teach them to use campfire ashes or pulverized, dried, burned bone fragments. These have an astringent, drying-up effect when you brew them into a tea." Tannic acid. But what if you're fresh out of pulverized, dried, burned bone fragments? "Anything that has tannic acid will stop the muscular contractions of the intestines," Sgt. Squier says. "Try acorns or the bark of oak trees or other hardwoods, boiled into a tea." Blackberry root. "Another real specific remedy that's easy to find in most of the temperate world is blackberry roots, again made into a tea," he says. "For any of these things, if you don't have hot water, you can soak them in cold, but it takes longer." Plantain. "Plantain grows in everybody's lawns," Sgt. Squier says. "Both broadleaf and narrowleaf varieties are strongly astringent. And the other half of Kaopectate in pectin," he notes. "It comes from apples and is used for making jelly. Cooking down apple peels and drinking the liquid is another diarrhea remedy." Blueberries. Finally, the blue-beary facts on turista. "It may be an old wives' tale, but one reason bears are so angry at certain times of the year is that they're gorging on blueberries, which make them constipated," says Sgt. Squier. "They get real severe cramps. One Alaskan trapper told me you can hear the bears' stomachs growing from quite a distance. I know I gorged myself on blueberries in Vermont and I couldn't go to the bathroom for three days. The old-timers say that if you take a few dried blueberries along on your trip, five or six of them will cure diarrhea." Any questions?

The nonformula. If you can't get your hands on the solutions, drink clear fruit juices, caffeine-free carbonated beverages, or weak tea with sugar. Also use these to supplement your rehydration solution.

Put your bladder to the test. The more yellow your urine, the more fluid you need. It should be clear. "As a minimum," Dr. Bezruchka says, "you should pass two busting bladders of urine a day, preferably more."

Avoid milk products and solid foods. At least at the beginning. They're too hard to digest. And stay away from alcohol—it dehydrates you. When the diarrhea stops, eat easily digested solids, like bananas, applesauce, saltine crackers, or rice.

Get in the pink. Pepto-Bismol, the well-known over-the-counter stomach medication, can be the traveler's friend. It can cut down on evacuations by about 60 percent, makes stools bulkier and firmer, and kills bacteria.

Some experts believe, however, that the slowing of diarrhea means the bug will stay inside you longer. Antidiarrheal drugs may also adsorb your rehydration solution. But at a certain point, you may not care. And don't worry about your tongue and diarrhea turning black. It's a natural side effect of Pepto-Bismol. Other adsorbents are Donnagel, Kaopectate, Quiagel, and Rheaban.

Do a little coaxing. Natural fiber-based laxatives for relieving constipation, such as Metamucil and Citrucel, also help with diarrhea. Some can absorb up to 60 times their weight in water to form a gel in the intestine. "You're still going to expel excess water," Dr. Gossel says, "but it won't be so runny. It may cut you down from ten times a day to seven or eight." Other brands are Equalactin, FiberCon, and Mitrolan.

Try opiates for quick relief. Opium-based antidiarrheal drugs inhibit intestinal contractions, cutting down on bowel movements and allowing absorption of water and electrolytes. These highly effective drugs, which can be purchased over-the-counter in some states, come as liquids, tablets, or suspensions. Brand names include Banatol, Donnagel-PG, and Quiagel PG. Loperamide, found in the brand Imodium AD liquid, is the newest OTC opiatelike antidiarrheal in the United States. Some states allow OTC purchase of paregoric, which is found in Parepectolin. These products will slow your Katmandu quickstep to a crawl.

One caution: Like adsorbents, the opiates' ability to plug you up may keep the bug inside a bit longer.

Reach for easy-access antibiotics. Although antibiotics are prescription drugs in the United States, they are readily available over-the-counter in many foreign countries. "TMP/SMZ and doxycycline [Vibramycin] have been well studied, and they work," Dr. Bezruchka says. "When I tried these, almost always just one dose would do the job. I think all you're doing here is helping your body by killing off most of the bacteria and letting your body handle the rest." He advises one TMP/SMZ or doxycycline pill twice a day until the diarrhea stops. But before you leave home, get your doctor's okay to use these drugs.

Do the double dose. Your Hong Kong dog will stop barking quickly if you take an antibiotic with an antidiarrheal drug. Caution: Antibiotics are powerful drugs and can have severe side effects, including sun sensitivity, and may open the door to another invasion of turista. Again, check with your doctor.

Fight bacteria with bacteria. Khem Shahani, Ph.D., a professor of food science and technology at the University of Nebraska, and others have discovered that the bacteria lactobacillus may be just the bacteria your poor, runny insides need. "They favorably alter the gut's microecology," he says, "and produce substances that inhibit the growth of disease-causing bacteria."

And, Dr. Shahani says, "It's been proven very effective to follow antibiotic therapy with lactobacillus because the gastrointestinal system has lost most of its beneficial microorganisms."

The best form of lactobacillus seems to be acidophilus, found in acidophilus milk, followed by bulgaricus, the type found in yogurt. You can buy capsules containing acidophilus and bulgaricus in pharmacies and health food stores in the United States and take them with you. They are not as effective as yogurt or acidophilus milk, says Dr. Shahani.

Abroad, the local versions of yogurt will be the easiest forms of lactobacillus to find. In Japan yogurt is called yakult; in Korea, yaogurt; in India, dahi; in Egypt, leben and lebenraid; in Turkey, eyran, and in Sardinia, gioddu.

PANEL OF ADVISERS

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Stephen Bezruchka, M.D., is an emergency physician at Providence Medical Center in Seattle, Washington, and author of The Pocket Doctor.

Thomas Gossell, Ph.D., R.Ph., is a professor of pharmacology and toxicology at Ohio Northern University in Ada and chairman of the university's Department of Pharmacology and Biomedical Sciences. He is an expert on over-the-counter products.

Khem Shahani, Ph.D., is a professor of food science and technology at the University of Nebraska in Lincoln.

SFC Thomas Squier, of the U.S. Army Special Forces, is an instructor at the JFK Special Warfare Center and School, Survival-Evasion-Resistance-Escape/Terrorist Counteraction Department in Fort Bragg, North Carolina. He is a Cherokee herbologist and grandson of a medicine man. He also writes a newspaper column called "Living off the Land."