Central  South  Dakota  Medical News
The Clinical View
by Phillip Hoffsten2005
24 November 2004

A TRAVELER’S WOES

     During the first two weeks of November, my wife and I took a trip to Mexico.  We had the opportunity to stay on a beach and enjoy the warm sunshine and pleasant sea breezes. But there was another poor soul on the beach with us that seemed to be spending more time in the bathroom than he was on the beach.  Considering the circumstances, this was a favorable situation.  Through chitchat conversation with others at the beach, he found out I was a physician and asked for help on what to do to deal with his very significant discomfort at this point.

     A quick history taken at that point indicated that he had not limited his foods to those at the hotel that we were staying at.  He had eaten in several local restaurants.  Specifically, he liked the salsa prepared “the Mexican way”.  He was having slight abdominal cramping but was not bleeding and was not nauseous or vomiting.

     Fortunately his story was not one that was dangerous.  His problem was uncomfortable and inconvenient, but left to natural history would clear in 2-3 days.  Fortunately at the hotel there was a sundries shop that provided Pepto Bismol and Imodium.  I advised him that the most important step in his care was to maintain adequate hydration with juices, pop, water, or soups.  Second, he was advised that he needed to use Imodium with 4 mg of a loading dose followed by 2 mg with each loose stool for a maximum of 8 pills per day.  Third, the most important step in my estimation was the addition of Pepto Bismol, taking one ounce of the liquid about every half hour to an hour, for a total of 8 doses to saturate the intestine secretory ability.  Fortunately the following day this unfortunate individual was much improved and by the second day had cleared completely.

     Separating individuals, such as the one described above from those who have a more dangerous situation is relatively easy.  Most cases of “traveler’s diarrhea” do not result from disease-causing bacteria.  Rather the problem seems to result from a change in nature of the bacteria in a person’s bowel.  Ironically Europeans coming to the United States complain as much about this problem as United States citizens going to Mexico.  By the same token, the Mexican population coming to the United States experiences the same problem when they consume our food and water.  Thus, an antibiotic plays no part in this type of problem.  Specifically, if the person’s problem is a watery diarrhea with slight cramping but no fever, no bleeding or no nausea or vomiting, the problem is best treated with Pepto Bismol and Imodium along with hydration as described above.

     The gentleman above inquired as to whether or not he needed to go to a hospital and was reluctant to believe that he didn’t need an antibiotic.  I indicated to him that as long as he was able to consume fluids adequate to his volume of diarrhea, there was really no danger to his situation.  It is an interesting fact of bowel physiology that there are 26 quarts of fluid secreted into the bowel each day.  Fortunately in a normal situation virtually all 26 quarts of this fluid are reabsorbed back into the body bringing needed nutrients with it.  What happens in “traveler’s diarrhea” is an inhibition of the pumps that reabsorb the fluid out of the bowel.  Thus, the body secrets fluid into the bowel but doesn’t reabsorb all of it and diarrhea results.  In extreme cases such as cholera, the person can have 15 quarts of stool per day and it is no wonder that this would be a fatal situation if the fluids were not replaced.  While cholera used to be a uniformly fatal condition, we now have learned that the only treatment necessary is fluid replacement to keep up with the volume of diarrhea and the person will recover spontaneously in several days without the use of an antibiotic.

     I explained to the gentleman that there were situations where hospitalization might be necessary.  For those individuals who develop nausea and vomiting with inability to replace the fluid being lost, intravenous fluids may be necessary.  In addition if there is bleeding with the diarrhea, this portends a different problem and generally will require an antibiotic. Situations in which there is bleeding per rectum along with nausea and vomiting are often accompanied by high fevers and more extensive medical evaluation is certainly indicated in this situation.

     For those individuals planning international travel, access to Pepto-Bismol and Imodium can be an important step for the trip.  Fortunately Mexican hotels are well stocked and taking supplies with you are not necessary.  For those going to more remote areas where medications might not be necessary, taking enough Pepto-Bismol pills and Imodium pills might be an important step for the trip.

     Patients often ask me if they can have a prescription for an antibiotic to take with them when they travel.  Using Ciprofloxacin at 750 mg daily can be an important step in care if the person develops fever, bloody diarrhea, and nausea, vomiting.  But it is not at all recommended that the antibiotic be started before the trip begins.

     As a last piece of advise, it was shown several years ago that salsa in many Mexican restaurants is contaminated with bacteria that are normally resident on tomatoes.  An author checked 57 salsa samples in lower Texas from Houston to Brownsville finding only three restaurant samples that were contaminated.  When he tested the same type of product in Mexico, it was found that over 60% of the salsa samples were contaminated with bacteria that could cause diarrhea.  Contaminated water and ice is often faulted as a source of infection but in modern hotels in Mexico this is infrequently a problem.

     Lastly, the gentleman in question above inquired about whether there were shots that he should get before he came on trips, such as to Mexico.  There are injections for prevention of typhoid fever and cholera.  Advice regarding the use of these injections can be obtained at your local clinic.  The answer is dependent upon where the person is traveling.  The Communicable Disease Center in Atlanta, Georgia publishes frequent bulletins regarding the appropriate immunizations for various areas a person might travel to.  Your local clinics have this information available on an up-to-date basis.