Understanding Diarrhea in Traveler

Diarrhea – general information (updated July 2023)


Nepal is a country with high risk for gastrointestinal illness. Approximately one third of patients who are seen at CIWEC Hospital do so for diarrhea. Risk of diarrhea is higher from April to September than in the cooler months. CIWEC has an ongoing research program to find out the cause and antibiotic resistance in travelers’ diarrhea.


What causes diarrhea?


Bacterial infections – Most cases (approximately 70-75%) of diarrhea are due to bacterial infections and are characterized by the abrupt onset of uncomfortable diarrhea and cramps. Nausea, vomiting, abdominal cramps, blood in stools and fever may or may not be present.Bacterial diarrhea can resolve spontaneously without medication but it can cause problems like dehydration, fatigue and loss of time from work or vacation. Replacement of lost fluids is important in preventing dehydration. Loperamide can be used for symptomatic treatment in mild cases and this may be all that is required. If the condition is severe and interferes with your travel plans, antibiotic therapy is recommended. If antibiotics are used, single dose therapy may be adequate.


In the past 3-4 years, it has been noted that travelers can acquire drug resistant bacteria in their gut which will persist for several months. Travel to South Asia, getting travelers’ diarrhea and using an antibiotic for it have been associated with high risk of carrying drug resistant bacteria in the gut which can then be taken back to the traveler’s home country. Due to this, judicious use of antibiotic in traveler’s diarrhea is now recommended by Travel Medicine practitioners around the world.


Viruses– Viruses are the second most common cause of diarrhea causing about 20% of all diarrhea in travelers to Nepal. There is significant vomiting associated with viral diarrhea which is watery most of the time. Antibiotics can be avoided if there is strong suspicion for a viral etiology of diarrhea.


Giardia – A parasite that causes a relatively low-grade, chronic diarrhea associated with stomach rumbling, gas, abdominal cramping and 3-5 loose stools per day.  It can sometimes cause a lot of watery diarrhea.  Fever almost never occurs with giardia.  Sulphurous smelling burps and farts, sometimes seen in Giardia infections, are equally common in bacterial infections and therefore not a reliable finding. Giardia is responsible for causing less than 10% of diarrhea diagnosis in travelers and expatriates in Nepal.


Cyclospora – Cyclospora is a protozoan parasite that causes infections from May to August each year. The disease can start with an abrupt onset of diarrhea and may be accompanied by low grade fever, nausea or vomiting. It then has a waxing and waning course with profound fatigue, loss of appetite, and diarrhea that comes and goes.  Untreated, the illness can last for several weeks.


Amebic Diarrhea – This is a very rare cause of diarrhea (approx. 1% only). Usual presentation seems to be chronic diarrhea alternating with constipation. Because it is so rare in travellers, empiric treatment is to be avoided in most situations.


WormsWorms are intestinal parasites that almost never cause diarrhea but may sometimes, cause mild abdominal pain. Hookworm is known to cause anemia.


Symptomatic Treatment of Diarrhea


When diarrhea or vomiting occurs, it is important to replace lost fluid and electrolytes to prevent dehydration. This can be done fairly easily with an electrolyte solution mixed in a liter of boiled water or one liter of mineral water. Some commercially available products are Nava Jeevan and Jeevan Jal. Other fluids that can supplement the oral rehydration solution are: Coca-Cola/sprite without the bubbles, herbal teas, clear soup, tang solution, Gatorade or weak tea. Alcohol and heavily caffeinated products should be avoided. It is important to urge young children with diarrhea to drink liquids frequently since they can get dehydrated quickly from seemingly small fluid losses. Adults should drink 3 liters or more per day depending on the amount lost as diarrhea or vomiting.


Bowel paralyzers, such as loperamide, can give temporary relief of abdominal cramps and diarrhea. To treat with loperamide, take 2 pills to start, and 1 pill after each loose stool (not to exceed 4 pills a day) until the diarrhea stops. If you have bloody diarrhea or fevers, do not use loperamide alone unless you take an antibiotic with it.


Water Purification and Food Precautions


All tap or ground water in Nepal must be assumed to be contaminated.  Bottled water in a one liter bottle is reasonably safe to drink. Water can be purified by bringing it to a boil. Battery operated small portable units that deliver UV light (e.g. SteriPEN) can disinfect clear water for drinking. Hotel and restaurant water that is said to be boiled and filtered may not always be.


Some restaurants soak their salad vegetables in iodine or iodine containing potassium permanganate solutions which render them safe to eat.  Otherwise, avoid any raw vegetable or fruit that cannot be peeled. Foods that are cooked once during the day, and then vaguely reheated before serving, such as quiche and lasagna are high risk foods because bacteria can multiply on them during the day.  Blended fruit and yoghurt drinks (“Lassis”) were found to be highly associated with diarrhea in our research and should be avoided.  Remember, you cannot completely control what you eat, and no matter how careful you are, you can still get ill.  Take reasonable precautions, as suggested, then relax and enjoy your food.


Stool Examination at CIWEC Clinic


We pride ourselves on our stool microscopy results.  You might wonder what is special about this simple test. Each stool sample is looked at in 2 ways at the clinic.  A fresh sample of stool is put on a slide and looked at under the microscope. Secondly, an equal volume of formalin ether is mixed with the stool and spun in a centrifuge. This method allows for digestion of fecal material and makes viewing of parasites easier. Some parasites like giardia are not always found in a single stool test necessitating multiple stool tests or empiric treatment for giardia by the physician.


Stool examination is a guide to therapy but a negative test result does not mean that there is no problem.