20
SECTION 5 • TR AVELER S’ D I A R R H E A
Clinical Presentation and Management of
Travelers’ Diarrhea
Thomas Löscher and Martin Alberer
Key points
• The clinical course and severity of travelers’ diarrhea (TD)
may be varied, and precise definitions based on number or
frequency of bowel movements in a 24 h period are arbitrary
• The mean duration of untreated TD is 3–5 days, but in 8–15%
a prolonged course (>1 week) occurs and in 1–3% chronic
diarrhea (>4 weeks) will develop
• 50% of patients with TD will be incapacitated for at least 1
day, 20% are confined to bed for 1–2 days, and 5–15% seek
professional medical help
• Risk groups prone to more severe and complicated illness are
the very young, the old, the immunocompromised, and
those suffering from underlying chronic medical conditions
• Diarrhea in travelers might be the initial presentation of
other potentially dangerous diseases, such as falciparum
malaria
Definition and Spectrum
Most studies define travelers’ diarrhea (TD) as the passing of three or
more loose stools in a 24 h period, in association with at least one
symptom of enteric disease1,2 such as nausea, vomiting, cramps, fever,
fecal urgency, tenesmus, or the passage of bloody, mucoid stools (Table
20.1). However, TD is not a distinct disease but a polyetiological
syndrome covering a broad spectrum of mainly infectious enteric
diseases caused by a considerable number of various pathogens (see
Ch. 18).3 Therefore, in everyday practice the limits of TD definition
are not absolutely precise. Even bowel disturbances that do not fulfill
the definition of classic TD (Table 20.1) may be of relevance to the
health of the traveler (mild and moderate TD), and can disrupt a
business commitment or other travel plans significantly.4 On the other
hand, diarrhea in travelers may be a symptom of severe or systemic
disease (Table 20.2), which can be difficult to distinguish clinically
from TD, at least in the beginning.5 In particular, it is important to
remember that diarrhea may be a symptom of falciparum malaria, and
that TD may be a fatal misdiagnosis in these patients.6
Signs and Symptoms
The clinical course and severity of TD vary considerably between
studies, depending on geographical differences and variation of the
©
2012 Elsevier Inc
DOI: 10.1016/B978-1-4557-1076-8.00020-X
microbial spectrum. TD usually does not start immediately upon
arrival, but typically after 3–4 days. Most cases, in some studies up to
90%, manifest during the first 2 weeks.7 Depending on the duration,
purpose, and destination of travel, two or more separate episodes of
TD were reported in 5–30% of travelers,4,7 representing new infec-
tions or relapses.
The typical attack begins abruptly. However, in some patients,
gastrointestinal symptoms start insidiously (seen more often in TD of
protozoal origin). The majority of patients have 3–5 diarrheal stools
per day. At least 20% of cases have more frequent bowel movements,
with ≥20 stools/24 h.1,2,7 In most patients the stool is watery. Visible
blood in the stool or the presence of bloody, mucoid stools (Fig. 20.2)
has been reported in 3–15% of classic TD.1,4 Concomitant symptoms
are frequent and often more disturbing than diarrhea itself. Fecal
urgency, nausea, abdominal pain or tenesmus are experienced by
almost all patients (Table 20.1). Urgency can be so strong that fecal
incontinence occurs. Vomiting does occur, most often within the first
hours of disease. Frequent vomiting may be very debilitating and can
contribute to significant electrolyte imbalance and fluid loss, especially
in infants.
Initial fever lasting for 1–2 days is common (Table 20.1) and has
been found at some destinations in up to 40% of patients with classic
TD.1,2 High-grade fever (sometimes with chills) or fever lasting longer
than 2 days is more common in classic TD and in cases with an identi-
fied pathogen.1,2 In addition to gastrointestinal symptoms and fever,
a variety of general symptoms may occur (i.e., myalgia, arthralgia,
cephalgia).
The majority of cases have a self-limited and uncomplicated course.
More severe and complicated disease requiring fluid or electrolyte
substitution and/or dysentery has been observed in 3–15% in different
studies.4,7 Fatalities from TD are exceedingly rare, and are seen almost
only in high-risk groups (see complications) or in severe or enteroin-
vasive diseases that are beyond the definition of TD (e.g., cholera,
shigella, or amebic dysentery).
Mild and moderate TD often last for 1–2 days only.7 Untreated,
the mean duration of classic TD in various studies has been 3–5 days.
However, in 8–15% a prolonged course (>1 week) is observed, and
in 1–3% chronic diarrhea (>4 weeks) will develop (see Ch. 21) 4,7.
Some patients develop irritable bowel syndrome after an episode
of TD, and this has been observed in up to 15% in travelers with
more severe TD.8
Almost half the patients with classic TD are incapacitated (defined
as inability to pursue planned activities) for a mean duration of 1 day.2