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Traveler's Diarrhea

Travelers' Diarrhea


Presentation

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].

Diarrhea
  • Postinfectious irritable bowel syndrome may occur in 3% to 17% of patients who have had traveler's diarrhea. Prevention of traveler's diarrhea by dietary avoidance measures is often not successful.[ncbi.nlm.nih.gov]
  • What is traveler's diarrhea? Traveler's diarrhea is a common medical problem for people traveling from developed, industrialized countries to developing areas of the world.[web.archive.org]
  • […] of traveler's diarrhea was studied.[ncbi.nlm.nih.gov]
  • Prevention In otherwise healthy adults, diarrhea is rarely serious or life-threatening, but it can certainly make for an unpleasant trip. Take steps to avoid diarrhea when you travel.[web.archive.org]
Abdominal Cramps
  • Watery and persistent diarrhea, fever, and abdominal cramps were common complaints.[ncbi.nlm.nih.gov]
  • The illness was self-limited in both cases but involved long-duration, watery diarrhea (10 to 50 days) accompanied by abdominal cramps and flatulence. This serotype should be taken into account as a possible cause of traveler's diarrhea.[ncbi.nlm.nih.gov]
  • Traveler's diarrhea is often accompanied by other symptoms, most often abdominal cramps.[ncbi.nlm.nih.gov]
  • Other commonly associated symptoms are nausea, vomiting, diarrhea, abdominal cramping, bloating, fever, urgency, and malaise. Most cases are benign and resolve in 1-2 days without treatment. TD is rarely life-threatening.[web.archive.org]
Acute Diarrhea
  • Abstract Acute diarrhea affects millions of persons who travel to developing countries each year. Food and water contaminated with fecal matter are the main sources of infection.[ncbi.nlm.nih.gov]
  • Acute diarrhea associated with international travel is commonly caused by enterotoxigenic Escherichia coli, enteroaggregative E. coli, or noroviruses.[ncbi.nlm.nih.gov]
  • Abstract Stool specimens from 124 international travelers with acute diarrhea were tested for the presence of enteropathogens.[ncbi.nlm.nih.gov]
  • IMPORTANCE: Acute diarrhea is the most common illness that affects travelers to low-income regions of the world. Although improved hygiene has reduced the risk of traveler's diarrhea in many destinations, the risk remains high in others.[ncbi.nlm.nih.gov]
  • In phase II and phase III clinical trials, concerns have been raised regarding the medicine's efficacy in terms of the time to last unformed stool and cure rate compared to current recommended antibiotics in the treatment of acute diarrhea caused by diarrheagenic[ncbi.nlm.nih.gov]
Chronic Diarrhea
  • Evaluation of the traveler with chronic diarrhea should include a careful examination for typical infecting organisms, such as Giardia and Entamoeba species, as well as for emerging parasites, such as Cryptosporidium species, Cyclospora species, and microsporidia[ncbi.nlm.nih.gov]
  • Causes: Chronic Diarrhea ( 14 days) VIII. Differential Diagnosis IX.[fpnotebook.com]
  • Persistent and Chronic Diarrhea in the Returning Traveler. In: Ericsson, Dupont, Steffen Travelers’ Diarrhea. Hamilton, Ontario: BC Decker, 2003[drconnornyc.com]
  • About one in 100 travelers develops chronic diarrhea that lasts more than 30 days. Chronic diarrhea is especially common in travelers with parasitic infections.[consumer.healthday.com]
  • The small number who continue to suffer symptoms will need careful evaluation to rule out the many causes of chronic diarrhea (such as lactase deficiency, irritable bowel syndrome, parasites, etc.).[medical-dictionary.thefreedictionary.com]

Workup

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.
Gram-Positive Rods
  • In vitro antibacterial activity has been shown against most of the gram-negative enteric pathogens, in addition to gram-positive rods and anaerobic bacteria ( 84 ).[doi.org]
HLA-B27
  • Among 3 members at risk, only the patient was positive for HLA-B27. Data from 3 similar families support the hypothesis that susceptibility to RS is genetically transmitted.[ncbi.nlm.nih.gov]
  • […] with insulin-dependent diabetes mellitus, congestive heart failure, advanced cancer, human immunodeficiency virus (HIV) infection, inflammatory bowel disease or other bowel abnormalities, reactive arthritis, reduced gastric acidity, or those who are HLA-B27[web.archive.org]
  • Other complications include Guillain-Barré syndrome after Campylobacter enteritis, Reiter’s syndrome (especially in persons who are HLA-B27 positive), Clostridium difficile colitis after antibiotic use, and postinfectious irritable bowel.[aafp.org]

Treatment

  • Single-dose treatment with azithromycin (1000 mg) and loperamide is as effective as single-dose treatment with levofloxacin (500 mg) and loperamide for noninflammatory diarrhea.[ncbi.nlm.nih.gov]
  • Antibiotic treatment is best reserved for cases that fail to quickly respond to loperamide. Antibiotic resistance is now widespread.[ncbi.nlm.nih.gov]
  • For the self-treatment of diarrhea that occurs during travel, all persons planning trips to high-risk areas should take with them medication with expected activity against the prevalent bacterial enteropathogens: rifaximin (for the treatment of common[ncbi.nlm.nih.gov]

Prognosis

  • What is the prognosis for travelers' diarrhea? The prognosis for travelers' diarrhea is usually good. Most cases resolve within 2 days without treatment. The CDC estimates 90% of cases resolve within one week, and 98% resolve within one month.[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]
  • Traveler's Diarrhea Prognosis Although it can ruin a vacation, traveler's diarrhea rarely requires hospitalization and usually is not life-threatening unless severe dehydration develops. Untreated, the diarrhea typically lasts three to five days.[emedicinehealth.com]
  • Prognosis Although traveler’s diarrhea can make anyone feel miserable, most people recover from the disease within 3 to 5 days with nothing worse than disrupted travel plans.[diet.com]
  • Prognosis Up to 1% of patients with TD will become sick enough to require hospitalization, and 3% will continue to experience diarrhea for at least one month. The majority of patients rapidly recover with minimal therapy.[medical-dictionary.thefreedictionary.com]

Etiology

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

Epidemiology

  • 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]
  • The microbiology, epidemiology, clinical presentation, and treatment of the most common intestinal parasites found in travelers are presented in this minireview.[ncbi.nlm.nih.gov]
  • Low-frequency restriction analysis of chromosomal DNA and pulsed-field gel electrophoresis and repetitive extragenic palindrome-PCR showed that both strains were epidemiologically related.[ncbi.nlm.nih.gov]
  • Epidemiological evidence suggests that PI-IBS is a relatively common sequela of acute gastroenteritis.[ncbi.nlm.nih.gov]
  • In addition, the simple molecular detection method utilized here will serve to facilitate more in-depth epidemiological studies of this emergent viral pathogen in travelers and other at-risk populations.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • Experimental evidence suggests that chronic inflammation following acute bacterial infection has a pathophysiological role in the development of PI-IBS.[ncbi.nlm.nih.gov]
  • Due to the great diversity of pathogens incriminated, several pathophysiological mechanisms have been described and some of them are still poorly understood.[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]
  • PATHOPHYSIOLOGY Virulence factors associated with ETEC include heat-labile toxin (LT), heat-stable toxin (STa), and various colonization factors (CFs) ( 130 ).[doi.org]

Prevention

  • 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]
  • Rifaximin offers a potentially useful approach for preventing traveler's diarrhea.[ncbi.nlm.nih.gov]
  • 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.[web.archive.org]
  • Probiotics may offer a safe and effective method to prevent TD.[ncbi.nlm.nih.gov]

Summary

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].

References

Article

  1. Yates J. Traveler's diarrhea. Am Fam Physician. 2005; 71(11):2095-2100.
  2. Giddings SL, Stevens AM, Leung DT. Traveler's Diarrhea. Med Clin North Am. 2016; 100(2):317-330.
  3. Ang JY, Mathur A. Traveler's diarrhea: updates for pediatricians. Pediatr Ann. 2008; 37(12):814-820.
  4. Kollaritsch H, Paulke-Korinek M, Wiedermann U. Traveler's Diarrhea. Infect Dis Clin North Am. 2012; 26(3):691-706.
  5. Steffen R, Hill DR, DuPont HL. Traveler's diarrhea: a clinical review. Jama. 2015; 313(1):71-80.
  6. Jiang ZD, Lowe B, Verenkar MP, et al. Prevalence of enteric pathogens among international travelers with diarrhea acquired in Kenya (Mombasa), India (Goa), or Jamaica (Montego Bay). J Infect Dis. 2002; 185(4):497-502.
  7. Paredes-Paredes M, Flores-Figueroa J, Dupont HL. Advances in the treatment of travelers' diarrhea. Curr Gastroenterol Rep. 2011; 13(5):402-407.
  8. Diemert DJ. Prevention and self-treatment of traveler's diarrhea. Clin Microbiol Rev. 2006; 19(3):583-594.
  9. Connor BA. Sequelae of traveler's diarrhea: focus on postinfectious irritable bowel syndrome. Clin Infect Dis. 2005; 41 Suppl 8:S577-586.
  10. McGregor AC, Whitty CJ, Wright SG. Geographic, symptomatic and laboratory predictors of parasitic and bacterial causes of diarrhoea in travellers. Trans R Soc Trop Med Hyg. 2012; 106(9):549-553.

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Last updated: 2019-07-11 21:25