This is the most frequent health problem of travellers to developing
countries. It is caused by a variety of infectious agents, usually
acquired by dietary indiscretion. It is characterized by frequent
(average 4 or 5) unformed bowel movements, often along with cramps,
nausea, bloating, malaise and fever. It usually begins abruptly and
is usually self-limited, lasting an average of 3 or 4 days.
When diarrhea starts it is
important to stop eating solid foods. If you have liquid stools, eat
a liquid diet. It is very important to drink lots of liquids. Water,
salt, sugar and potassium are essential. You should, therefore, drink
things such as broths, soups, fruit juices, and soft drinks in quantities
of 3 or more litres a day. If you cannot tolerate these well you should
take them in sips. You should avoid dairy products and alcohol at
this stage.
Packets of rehydration salts,
to be mixed with purified water, can be bought in many parts of the
world. Powdered Gatorade is available here in Canada and you could
think of taking this along with you. These are a suitable and palatable
way of getting the essential ingredients mentioned above. You can
make up your own rehydration fluid as well. You add 2 tbsp (1 hand
scoop) of sugar, 1/4 tsp (1 three-finger pinch) of salt, 1/4 tsp of
bicarbonate of soda (or another 1/4 tsp of salt if bicarb is not available)
and 1/2 cup of orange juice or a squeeze of lemon to 1 litre of purified
water to make up the solution.
When you have soft stools
and your bowel movements are less frequent eat a soft diet such as
bananas, rice, apple sauce, toast (or crackers), noodles and potatoes
that are not fried. When your bowel movements improve even more and
are more or less reqular for you a regular diet can be started again,
but keep the quantities small at first.
If your bowel movements are
unpredictable and you have to teach a class or take a bus or attend
a meeting, and if the diarrhea is not associated with blood in the
stools or high fever, you can start to take some anti-motility agent
such as Loperamide (Imodium®) (available over the counter) or Lomotil.
Loperamide is taken as 2 capsules right away and then 1 after each
loose bowel movement to a maximum of 8 capsules a day. You should
not use this for more than 48 hours, however. If your symptoms persist
this long you should seek medical attention.
If you develop severe diarrhea;
ie, if you have 3 to 5 unformed stools in a day, especially if they
are explosive or watery, you could start taking an antibiotic. Cholera
is one of the causes of such diarrhea. Studies have shown that this,
together with Loperamide (taken as 2 capsules right away and then
1 every 6 hours as needed), can shorten the length of time the diarrhea
lasts to a matter of hours only. If there is blood in your bowel movements
it is best to get medical advice first. If the severe diarrhea
is also associated with a fever or blood in the bowel movements you
should use the antibiotic alone, not with Loperamide. If there
is no fever or blood use both.
The best antibiotics to use
are one of the following: Ciprofloxacin 500 mg; Trimethoprim/Sulphamethoxazole
(TMP/SMX) Double Strength tablets; Noroxin 400 mg; Ofloxacin 300 mg;
Doxycycline 100 mg; TMP alone 200 mg or Levofloxacin (Levaquin) 500
mg. All of these are taken twice a day for 3 days except Levofloxacin
which is taken only once a day for 3 days. Yet another choice is Azithromycin
1000 mg once only. These provide a cure in most cases.
Antibiotics should not be
used as prophylaxis of diarrhea, but only as treatment. You should
avoid unnecessary exposure to the sun when you are taking either TMP/SMX
or Doxycycline. TMP/SMX cannot be used by people allergic to Sulpha.
Ciprofloxacin and Noroxin cannot be used by children under the age
of 15.
You should seek medical attention
if there is a high fever with shaking chills, large amounts of blood
in the stools, signs of dehydration (dry mouth, rapid pulse, dark
coloured urine, reduced amounts of urine) or if the diarrhea does
not resolve with the above measures.
R.J. Birnbaum,
MD, CCFP, FCFP
June 13, 2000