As per definition, TD comprises the passage of three or more unformed stools within 24 hours and at least one of the following symptoms: fever, nausea and vomiting, abdominal pain or cramps, fecal urgency, tenesmus, mucoid stools or hematochezia [8]. Borborygmi and bloating are often reported. Despite the frequent elimination of watery stools, TD is rarely severe enough to cause dehydration. However, dehydration may be observed in hot climates and patients who don't take the appropriate measures to rehydrate.

Although disease severity varies largely, most cases are self-limiting within three to five days [4]. Though, in up to 3% of cases, symptoms may persist for more than a month. If differential diagnoses are ruled out, these patients may possibly be diagnosed with post-infectious irritable bowel syndrome [9].

• Fatigue

  TD starts suddenly and in addition to diarrhea may include fever, vomiting, stomach cramps and fatigue. Most cases of TD last only a few days and are not life threatening, though some cases may last up to a month. [pennmedicine.org]

  Salmonella bacteria, one of many causes of travelers’ diarrhea Here are some warning signs; you should see a doctor if you have any of these high fever severe abdominal pain severe vomiting unable to eat/drink mucous-bloody stool fainting, severe fatigue [thaitravelclinic.com]

  A normal course of traveler's diarrhea lasts about 3 to 7 days, and may be accompanied by: nausea bloating urgency fatigue loose, watery stools Recommendations: Prevention of traveler's diarrhea: You can decrease your risk of developing traveler's diarrhea [childrensal.org]

  Symptoms The symptoms of traveler's diarrhea include: Abdominal pain Cramping Feeling bloated Continual feeling of needing to use the bathroom Nausea Loose, watery stools Fatigue Slight fever Rehydration tips The biggest problem with diarrhea is dehydration [worldnomads.com]

  So do simple things like jet lag, fatigue and a change of environment. [web.archive.org]

• Chills

  It’s unrealistic to expect home cooks to chill or reheat or discard dishes every two hours during a dinner party, or every hour at a summer barbecue. Dr. [web.archive.org]

  Seek medical help for traveler's diarrhea if: Diarrhea is severe, bloody, or does not resolve within a few days Diarrhea is accompanied by fever and chills You are unable to keep fluids down to prevent dehydration How Can I Protect Myself From Traveler's [webmd.com]

  Seek medical help when diarrhea is: severe. bloody. does not get better within a few days. accompanied by fever and chills. causes dehydration. Copyright 2009. UAB/International Adoption Clinic. All rights reserved. [childrensal.org]

  A few signs that you've reached this stage include the presence of blood in diarrhea (dysentery), high fever, chills, skin lesions and severe abdominal cramping. [worldnomads.com]

• Anemia

  Enterohemorrhagic E. coli (EHEC) is a type of EHEC, E.coli 0157:H7 that can cause bloody diarrhea and the hemolytic uremic syndrome (anemia and kidney failure). [medicinenet.com]

  H7, which cause a watery diarrhoea rapidly progressing to frank haemorragic colitis, itself leading in about 20% of paediatric patients to serious sequelae, including the haemolytic uremic syndrome (HUS) characterized by thrombocytopenia, hemolytic anemia [web.archive.org]

• Shivering

  Those indicating possible withdrawal and the need for medical attention if they occur after discontinuation of prolonged high-dose therapy Incidence rare {04} {06} {15} {16} Increased sweating muscle cramps nausea or vomiting shivering or trembling stomach [web.archive.org]

• Pertussis

  /Bordetella parapertussis Pertussis γ Enterobacteriales (OX−) Lac+ Klebsiella pneumoniae Rhinoscleroma, Pneumonia Klebsiella granulomatis Granuloma inguinale Klebsiella oxytoca Escherichia coli: Enterotoxigenic Enteroinvasive Enterohemorrhagic O157:H7 [en.wikipedia.org]

• Diarrhea

  Acute diarrhea is the most common illness among travelers. [aafp.org]

  Travel destination is the most significant risk factor for traveler's diarrhea. The efficacy of pretravel counseling and dietary precautions in reducing the incidence of diarrhea is unproven. [ncbi.nlm.nih.gov]

  Aemcolo was not shown to be effective in patients with diarrhea complicated by fever and/or bloody stool or diarrhea due to pathogens other than noninvasive strains of E. coli and is not recommended for use in such patients. [fda.gov]

• Nausea

  Other frequent stomach ailments, including nausea, upset stomach, indigestion, and heartburn caused by food or drink, also can spoil a trip. [pepto-bismol.com]

  Although nausea after dosing is uncommon, it is more frequently associated with azithromycin than with levofloxacin. [ncbi.nlm.nih.gov]

  Nausea, vomiting, abdominal cramping, and diarrhea can occur with any degree of severity. The diagnosis is usually based on the doctor's evaluation, but sometimes stool is tested for organisms. [msdmanuals.com]

  We also found that azithromycin administered in a single 1000-mg dose caused more postdose nausea than did levofloxacin administered at a dose of 500 mg, but associated nausea was rare (occurring in 7.6% of patients). [doi.org]

• Abdominal Cramps

  Watery and persistent diarrhea, fever, and abdominal cramps were common complaints. [ncbi.nlm.nih.gov]

  Travelers' diarrhea is defined as three or more unformed stools in 24 hours, commonly accompanied by abdominal cramps, nausea and bloating. [medical-dictionary.thefreedictionary.com]

• Abdominal Pain

  The presence of fever, bloody stool, abdominal pain, or profound dehydration indicates a more severe infection requiring medical attention. [ncbi.nlm.nih.gov]

  When to See a Healthcare Provider If diarrhea is bloody, or if you have a fever or abdominal pain, see a healthcare provider immediately. Do not take over-the-counter drugs. [webmd.com]

  Dehydration, the primary risk of turista The symptoms of traveler’s diarrhea generally appear in the very first days of a trip: multiple evacuations of liquid stool (at least 3 times per day), often along with nausea, abdominal pain, and loss of appetite [biocodexmicrobiotainstitute.com]

• Acute Diarrhea

  The use of nonspecific antidiarrheals, especially loperamide, is safe for most cases of acute diarrhea. [web.archive.org]

  Abstract Stool specimens from 124 international travelers with acute diarrhea were tested for the presence of enteropathogens. [ncbi.nlm.nih.gov]

• Hunger

  Those who feel like eating should try to do so--why add hunger pangs to your existing level of abdominal discomfort? Try to think of what would sound good to you in your present condition; this will be quite different for different people. [web.archive.org]

• Kidney Failure

  This can be followed by serious organ system damage such as kidney failure. You may be exposed to E. coli from contaminated water or food — especially raw vegetables and undercooked ground beef. [empr.com]

  Enterohemorrhagic E. coli (EHEC) is a type of EHEC, E.coli 0157:H7 that can cause bloody diarrhea and the hemolytic uremic syndrome (anemia and kidney failure). [medicinenet.com]

• Renal Function Impairment

  impairment or jaundice (diphenoxylate may precipitate hepatic coma; it is recommended that dosage be reduced in patients with impaired hepatic function {01} {04} {06} {15} {16} {23} ) Hiatal hernia associated with reflux esophagitis (although unlikely [web.archive.org]

• Dizziness

  The study demonstrated equivalent clinical responses with regard to diminishment of diarrhea or subjective findings such as abdominal pain/cramps, headache, dry mouth, dizziness, or thirst. [ncbi.nlm.nih.gov]

  Symptoms of dehydration include feeling very thirsty, lightheadedness, dizziness, dark urine and decreased urine frequency. Bananas and rice help settle the stomach during diarrheal illnesses, while water aids in rehydration. [emoryhealthcare.org]

  […] fluid retention in colon and may further aggravate dehydration; discontinuation of medication and rehydration therapy is essential if signs or symptoms of dehydration, such as dryness of mouth, excessive thirst, wrinkled skin, decreased urination, and dizziness [web.archive.org]

  You have signs of dehydration such as dizziness, weakness, dry skin, lack of tears or urine or sunken eyes. The diarrhea becomes more severe, painful or if blood or mucus appear in the stool. [healthcenter.indiana.edu]

  You are dizzy or lightheaded. When should I contact my healthcare provider? Your symptoms do not get better with treatment. Your diarrhea lasts for more than 7 days. You have questions or concerns about your condition or care. [drugs.com]

The diagnosis of TD is based on anamnestic data and clinical symptoms. Since the majority of cases is self-limiting, additional diagnostic measures are rarely carried out. Nevertheless, it may be necessary to rule out more severe gastrointestinal disorders in cases of persistent diarrhea, hematochezia, or atypical complaints. Here, the following measures may be helpful:

• Bacteriological examination of stool samples, stool cultures. If anamnestic data and clinical presentation are consistent with TD, Enterobacteriaceae or Campylobacter spp. are most likely to account for the disease. Still, the patient's travel destination and medical history may indicate the need for an expansion of the diagnostic range.
• Microscopic examination of stool samples to reveal the presence of parasites.
• Persistent diarrhea is indicative of parasitic disease; fever, enhanced serum concentrations of C-reactive protein, and fecal leukocytes are more frequently associated with bacterial TD [10].
• Viruses may be detected in stool samples employing electron microscopy, antigen detection assays, or molecular biological techniques, among others.
• Testing of stool samples for Clostridium difficile toxin, particularly if the patient has recently taken broad-spectrum antibiotics.

Algorithmic approach to the treatment of traveler’s diarrhea Information from references 33 and 34. Approach to the Treatment of Traveler’s Diarrhea Figure 1. [aafp.org]

Empiric treatment of traveler's diarrhea with antibiotics and loperamide is effective and often limits symptoms to one day. [ncbi.nlm.nih.gov]

Latest Travel Health News What is the prognosis for travelers' diarrhea? The prognosis for travelers' diarrhea is usually good. Most cases resolve within 2 days without treatment. [medicinenet.com]

Prognosis: Course Most cases of Traveler's Diarrhea are self limited and last Images: Related links to external sites (from Bing) Ontology: Traveler's diarrhea (C0277528) Concepts Disease or Syndrome ( T047 ) SnomedCT 186165000, 367091004, 11840006 English [fpnotebook.com]

Pathogens associated with TD comprise [6] [7]:

• Escherichia coli spp., especially enterotoxigenic strains, enteroaggregative strains
• Shigella spp.
• Salmonella spp.
• Campylobacter spp.
• Aeromonas spp.
• Plesiomonas spp.
• Vibrio spp.

• Entamoeba histiolytica
• Giardia lamblia
• Cryptosporidium spp.

• Norovirus
• Rotavirus
• Enteric adenovirus

SUBJECTS: To investigate epidemiology and impact, 30369 short-term visitors completed a questionnaire just before boarding their homebound aircrafts. To investigate etiology, 322 patients (hotel guests) with TD provided stool samples. [ncbi.nlm.nih.gov]

References 1 World Health Organization ., Food safety and foodborne illness, 2002 Geneva World Health Organization Fact sheet 237 2 Epidemiology, etiology, and impact of traveler' diarrhea in Jamaica, JAMA, 1999, vol. 281 (pg. 811 - 7 ) 3 Epidemiology [doi.org]

Experimental evidence suggests that chronic inflammation following acute bacterial infection has a pathophysiological role in the development of PI-IBS. [ncbi.nlm.nih.gov]

Intestinal electrolyte fluid movement explains the pathophysiology of most cases while in certain situations osmotic diarrhea or altered intestinal motility may lead to passage of unformed stools. [karger.com]

Sleisenger & Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 6th ed. Philadelphia, PA: WB Saunders; 1998:128–152. Gangarosa RE, Glass RI, Lew JF, Boring JR. [web.archive.org]

Prevention and self-treatment of travelers’ diarrhea. Prim Care 2002;29:843–55. Department of Health and Human Services. Centers for Disease Control and Prevention. Travelers’ Diarrhea. [racgp.org.au]

CONCLUSIONS: The WC/rBS cholera vaccine prevents TD in 2 out of 7 travelers (preventive fraction: 28%). The number needed to vaccinate (NNV) to prevent 1 case of TD is 10. [ncbi.nlm.nih.gov]

Traveler's diarrhea (TD) is an unspecific term referring to distinct types of gastrointestinal infections that affect travelers and result in acute diarrhea, i.e., the passage of three or more unformed stools within a period of 24 hours [1]. It is the most common travel-related illness [2] and typically occurs within the first two weeks of traveling. Bacteria account for most cases of TD, but parasites and viruses may also trigger the disease. Pathogens are generally ingested with contaminated water or food, and first symptoms manifest within hours or few days after exposure. Patients are not necessarily aware of risky behavior since an infection may result from seemingly insignificant actions like cleaning one's teeth with a brush rinsed in non-potable water. Symptoms may persist for several days.

Oral rehydration is the mainstay of treatment and aims at compensating for water and electrolyte loss [3] [4]. Furthermore, self-treatment of TD often includes the use of antimotility drugs like loperamide, but patients should be advised on the potential risks of such therapy [4]. Antibiotics may be indicated in case the disease is caused by bacterial pathogens, but this therapeutic approach is associated with considerable disturbances of the normal intestinal flora. Thus, the use of antibiotics is not generally recommended unless a patient suffers from moderate to severe TD [5].

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