Every year it is estimated that international travelers, the target of this syndrome, are affected at a rate ranging from 20 to 30 percent (quantifiable at approximately 10 million subjects). The risk depends on the destination of travel, and the highest number relates to business or vacation travel in developing areas (Africa, the Middle East, Latin America, and Asia). It can occur suddenly during travel or even after return home.
Most commonly the cause is related to ingestion of food and water contaminated with fecal material. It can easily be found in waters that lack safe and adequate purification.
Beyond food and drink, we must remember the other sources such as:
- brushing teeth;
- the ice;
- fruits and vegetables treated with contaminated water;
- undercooked or raw foods especially fish;
- locations that are poorly cleaned or have flies.
Let's not forget that paying attention to the above helps us avoid various food-borne diseases, in addition to the so-called traveler's diarrhea: hepatitis A, parasitic infections, typhoid.
With regard to microorganisms about 80% can be identified as bacteria, 8-10% viruses and 10% intestinal pathogenic protozoa: apart from "the king" of traveler's diarrhea (Escherichia coli) we can remember Campylobacter jejuni, Salmonella spp, Shigella dysenteriae and spp. Among viruses noroviruses, rotaviruses, caliciviruses, while among protozoa Giardia lamblia and the rarer Entamoeba coli and histolytica.
These are the most common.
We must, however, distinguish it from food poisoning, diarrhea accompanied by vomiting due to ingestion of toxins with food (which resolves in a few hours).
We therefore have three forms:
- bacterial form: incubation period 6-48 hours, appears suddenly with cramps in the lower quadrants of the abdomen, diarrheal discharges, fever, sometimes vomiting and sometimes blood during evacuation;
- Viral form: incubation period as for bacterial 6-48 hours. Clinical also similar but with more profuse vomiting (norovirus);
- protozoal form: incubation period 1-2 weeks and therefore rarely occurs in the early travel period. Symptoms are less violent and intense, rarely vomiting and 2 to 4 diarrheal discharges per day.
If these forms go untreated they have a variable average duration: 3-5 days the bacterial one, 2-3 days the viral. Protozoal forms can persist for even very long periods, from weeks to months.
Subjects most at risk include, among them as already highlighted immunocompromised, diabetics, those who have hypochlorhydria (low gastric hydrochloric acid) from medications, and those with inflammatory bowel disease. These particularly susceptible individuals, before travel to high-risk locations, should perform pre-trip counseling and follow prophylaxis indicated by a travel medicine specialist.
In these travelers, there is a higher risk of complication of the clinical picture of traveler's diarrheae. Complication identifiable with dehydration and alterations in water and salt balance, reminiscent of forms of cholera. Salts lost through diarrhea and vomiting are mainly represented by potassium, which should definitely be replenished.
Prophylaxis should be reserved for those mentioned to be at risk of more enduring, intense and severe forms. Initial coverage is also provided by oral cholera vaccine (particularly against E. coli).
One of the earliest agents against microorganisms, already evaluated and used, was bismuth subsalicylate (but with side effects of the tongue and stool blackening type; cannot be used, however, in renal failure, allergy to salicylates, and subjects being treated with anticoagulants). Some doubt in the literature relates to true benefits achievable with prophylaxis by probiotics such as milk enzymes.
That antibiotics are certainly effective in prevention: doxycycline, rifaximin.
But you need to follow indications from your primary care physician or a physician who specializes in Travel Medicine.
Behavioral Prophylaxis
- before meal wash and disinfect hands well; .
- drink water or bottled beverages (or boil it);
- brush your teeth with bottled mineral water;
- avoid unsealed drinks and ice;
- eat cooked and hot foods (especially fish), then avoid raw foods;
- avoid fruit salads;
- eat places that appear clean, tidy and fly-free;
- before leaving go to traveler's or tropical medicine centers to get an overview "card" of the risks that can result from traveling to developing countries or countries with poor sanitation. The issue will also be explained with all the useful tips for avoiding or dealing with it.
Therapy
Many diarrheal episodes are self-limiting with rapid resolution. Rehydration is certainly important, particularly for the elderly and children. Milk enzymes are particularly useful for "restructuring" intestinal flora during and after diarrheal attacks.
The use of antibiotics also helps to reduce the duration of symptoms to a limited extent.
Naturally, therapy must involve the simultaneous intake of fluids and appropriate feeding measures to "sustain" the therapy in effectiveness, avoiding possible consequential dehydration, with loss of salts and electrolytes as well. Fluids should be rich in potassium and sodium. Such intake would be helpful if it contained alkalizing substances, to counteract the possible acidosis that accompanies traveler's diarrhea.
Diet
To help the body, we recommend avoiding alcohol, coffee, sugary drinks and salt-type sports drinks (they are hyperosmolar and rich in sugar thus worsening the intestinal situation). Foods should be, after the first day of symptoms, low in fiber and digestible, in small meals throughout the day. Particularly recommended are dry foods, such as crackers, rice and pasta, pureed apples or carrots. The protein portion should be low in fat (lean steamed fish extremely recommended).
We emphasized a diet low in fiber, so avoid whole grains, vegetables and fruits.
But why then are pureed apples or carrots recommended?
Because they feature pectin, a soluble fiber with absorbent properties that can give stool texture. Even bananas can be used because, in addition to their richness in potassium, they have resistant starch, fermented by the intestinal flora, which produces short-chain fatty acids that are essential for the mucous membrane of the intestine.
They are also recommended because they are rich in potassium.
Some food science specialists, for this type of diarrhea recommend the Bratty diet, an acronym reminiscent of:
- Bananas (bananas);
- Rice (rice);
- Applesance (apple puree);
- Tea (tea);
- Toast;
- Yogurt;
Recommended milk enzymes
.We recommend these two types of milk enzymes:
- Lactobacillus Acidophilus which is generally indicated in diarrhea with dyspepsia or colitis;
- Saccharomyces boulardii.
Conclusions
In conclusion, "Montezuma's Vendetta" as traveler's diarrhea is called, generally has a benign course. It resolves without treatment in a maximum of 2 days. If symptoms persist, refer to the above, but if the diarrhea becomes bloody and vomiting repeated several times, a specialist in travel medicine should be heard from for possible differential diagnosis.
For international travel to developing countries, other conditions should also be thought of. For example: bloody diarrhea, high fever, profuse watery diarrhea with mucus stains (the classic "rice water" stools) may suggest consideration of cholera.
These are the most common pathologies.
So abroad, Africa, the Middle East, Asia, Central and South America, let's be careful about foods and drinks that do not adversely affect the locals. This situation occurs because of the immunity that develops due to constant exposure to pathogens found in water and food of their daily consumption.
