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Persistent Diarrhoea in a Returned Traveller

by Dr Bob Kass - October 10, 2016

".........at 4.00am he was awakened with a start desperately aware that he was about to move his bowels. He traversed the bed to bathroom distance in what must have been record time and relieved himself of a totally watery bowel movement which was accompanied by slight transverse colon cramps. The patient returned to bed in a stunned state only to discover that no sooner had he arrived than he was constrained to leave again, with unaccustomed alacrity. This staccato ballet continued at 15 minute intervals with the patient exhibiting progressive weakness, profound malaise, increasing severe cramps, almost constant nausea and several episodes of vomiting".      

- Dr Kean - Annals of Internal Medicine 1963

Dr Kean’s description of Traveller’s Diarrhoea (TD) will be familiar to many travellers.  (Most people recognise it as Bali Belly, Delhi Belly, The Tokyo Trots, The Ho Chi Minhs, Montezuma’s Revenge, The Mexican Two Step or Cleopatra’s Curse!)

More than 40% of travellers will experience a bout of traveller’s diarrhoea during travel to a less developed region of the world. High risk destinations include Egypt, Morocco, Zanzibar and Central America.  It is usually self-limiting but can still ruin a well-planned holiday or business trip. 

Up to 20% of people will lose at least a day and 5% more than 3 days. Travel to more developed regions is not without risk. If you eat out for every meal then you are relying on the personal and foodhygiene of a lot of strangers!

For some unfortunate individuals (probably less than 3%) gastrointestinal symptoms may persist for weeks, even months afterwards.

We call this “post-infectious irritable bowel syndrome”

Reducing the risk of traveller’s diarrhoea is obviously very important and understanding the do’s and don’ts of eating and drinking safely can easily be covered in any travel medicine consultation

The assessment and management of persistent diarrhoea after travel is not so straight forward and usually involves a step-wise multidisciplinary approach. This usually begins with a poo sample to determine whether any pathogens (disease-causing bacteria or parasites) are present in the gut.

Occasionally something treatable is found but more often than not, the original culprit has left the scene. The symptoms that persist are the result of damage done to the lining of the intestine which affects the ability to absorb particular components of the diet. This won’t happen to everyone, but particular pathogens may impact on those with a predisposition.

Current thinking on this disorder suggests a problem with altered motility, increased permeability and ongoing intestinal inflammation due to a specific intestinal pathogen. Likely pathogens include, Campylobacter, Salmonella and Shigella. The duration of the acute episode of diarrhoea correlates well with the risk of Post Infectious-IBS. The longer the initial episode the more likely is the development of Post Infectious-IBS.

So what can I do to reduce my Post-Infectious IBS symptoms?

Diarrhoea symptoms are much more common in Post Infectious-IBS than constipation. It is also characterised by bloating, abdominal pain and explosive rectal urgency. Mucous may be observed in the stool.  Weight loss isn’t common.

The dietary management of Post-Infectious-IBS is very important.  Consuming a diet that aggravates the condition can prolong the recovery phase.  Resting the bowel must be seen in the same context as resting a limb after a musculoskeletal injury.

The role of the Dietitian is very important in helping the individual understand what foods can be easily managed by the gut and to avoid those more likely to exacerbate the symptoms. A diet high in fibre may not be sensible and consuming particular foods may have to be limited or stopped all together.  Gradual re-introduction of these high-risk foods, however, is important.

According to Joyce Haddad (Dietitian and Nutritionist), a common group of molecules in carbohydrate foods are poorly absorbed during gut dysfunction (PI-IBS) and this can cause unwanted symptoms such as bloating and explosive diarrhoea. The abbreviation FODMAP is often used to describe this group of molecules.

  • Fermentable

  • Oligosaccharides (e.g. Fructans and Galactans)

  • Disaccharides (e.g. Lactose)

  • Monosaccharides (e.g. Fructose in excess of Glucose)

  • And

  • Polyols (e.g. Sorbitol and Mannitol)

FODMAPs are problematic because they are a food source for the bacteria that live in the large intestine. When the bacteria digests/ferments these FODMAPs, unwanted symptoms can occur.

Dietary restriction of these poorly absorbed FODMAP foods (i.e. a low FODMAP diet) is a specialised area of nutrition. Dietary changes are involved and the best outcomes are achieved in consultation with a dietitian.  Joyce Haddad is able to provide you with expert advice to ensure that your food intake remains balanced and nutritionally complete while following the low FODMAP diet.  She will then guide you through the reintroduction of FODMAP items into your diet as your PI-IBS resolves.

To book an appointment with Joyce, please contact the reception staff at Globe Medical on (08) 8232 7372 or book online.

Image Credit: Karyn Christner, Flickr


Dr Bob Kass

Dr Bob Kass is Medical Director of Globe Medical. He holds specialist qualifications in paediatrics and public health medicine and is one of Australia's pioneers in the discipline of Travel Medicine. 

Full professional biography | Book an Appointment with Dr Kass