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Chronic Diarrhea in Travelers

  • Tropical, Travel and Emerging Infections (L Chen, Section Editor)
  • Published:
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Abstract

As a rule, travelers’ diarrhea is a self-limited bacterial infection that affects approximately 40 % of travelers to developing countries. Health-care professionals who see returning travelers have noted that some travelers afflicted with diarrhea do not recover completely but, instead, develop chronic diarrhea or a persistent change in gastrointestinal function. Concurrent with this observation has been the recognition that in many patients with long-standing irritable bowel syndrome, an episode of traveler’s diarrhea or gastroenteritis preceded the onset of symptoms. Before a diagnosis of postinfectious irritable bowel syndrome is considered, other diagnostic considerations must be excluded. This review will examine an approach to the patient with chronic diarrhea posttravel.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Connor BA. Travelers' Diarrhea. Centers for Disease Control and Prevention: Health Information for International Travel 2012: Yellow Book. 2012 Oxford University Press 56–60.

  2. Shlim DR, Hoge CW, Rajah R, et al. Persistent High Risk of Diarrhea among Foreigners in Nepal during the First 2 Years of Residence. Clin Infect Dis. 1999;29(3):613–9.

    Article  PubMed  CAS  Google Scholar 

  3. Hoge CW, Shlim DR, Echevarria P. Epidemiology of diarrhea among expatriate residents living in a highly endemic environment. JAMA. 1996;275:533–8.

    Article  PubMed  CAS  Google Scholar 

  4. Taylor DN, Houston R, Shlim DR. Etiology of diarrhea among travelers and foreign residents in Nepal. JAMA. 1988;260:1245–8.

    Article  PubMed  CAS  Google Scholar 

  5. Ortega YR, Adam R. Giardia: overview and update. Clin Infect Dis. 1997;25:545–50.

    Article  PubMed  CAS  Google Scholar 

  6. Addis DG, Mathews HM, Stewart JM. Evaluation of a commercially available enzyme-linked immunosorbent assay for Giardia lamblia testing in stool. J Clin Microbiol. 1991;29:1137.

    Google Scholar 

  7. Goka AK, Rolston DD, Mathan VI. The relative merits of faecal and duodenal juice microscopy in the diagnosis of giardiasis. Trans R Soc Trop Med Hyg. 1990;84:66.

    Article  PubMed  CAS  Google Scholar 

  8. Hoge CW, Shlim DR, Rajah R, et al. Epidemiology of diarrhoeal illness associated with coccidian-like organism among travellers and foreign residents in Nepal. Lancet. 1993;341(8854):1175–9.

    Article  PubMed  CAS  Google Scholar 

  9. Connor BA, Shlim DR, Scholes JV, et al. Pathologic changes in the small bowel in nine patients with diarrhea associated with a coccidian-like body. Ann Int Med. 1993;119:377–82.

    Article  PubMed  CAS  Google Scholar 

  10. Hoge CW, Shlim DR, Ghimire M, et al. Placebo-controlled trial of co-trimoxazole for Cyclospora infections among travelers and foreign residents in Nepal. Lancet. 1995;345:691–3.

    Article  PubMed  CAS  Google Scholar 

  11. Bhan MK, Raj P, Levine MM. Enteroaggregative Escherichia coli associated with persistent diarrhea in a cohort of rural children in India. J Infect Dis. 1989;159:1061–4.

    Article  PubMed  CAS  Google Scholar 

  12. Gascôn J, Vargas M, Quinté L. Enteroaggregative Escherichia coli strains as a cause of travelers’ diarrhea: a case control study. J Infect Dis. 1998;177:1409–12.

    Article  PubMed  Google Scholar 

  13. Golledge CL, Riley TV. Clostridium difficile-associated diarrhea after doxycycline malaria prophylaxis. Lancet. 1995;345:1377–8.

    Article  PubMed  CAS  Google Scholar 

  14. Farthing MJG. Tropical malabsorption and tropical diarrhea. In: Feldman M, Scharschmidt BF, Sleisenger MH, editors. Sleisenger & Fordtran’s gastrointestinal and liver disease. 6th ed. Philadelphia: WB Saunders; 1998. p. 1574–84.

    Google Scholar 

  15. Klipstein FA. Tropical sprue in travelers and expatriates living abroad. Gastroenterology. 1981;80:590–600.

    PubMed  CAS  Google Scholar 

  16. Cook GC. Aetiology and pathogenesis of postinfective tropical malabsorption (tropical sprue). Lancet. 1984;i:721–3.

    Article  Google Scholar 

  17. Osterholm MT, MacDonald KL, White KE. An outbreak of a newly recognized chronic diarrhea syndrome associated with raw milk consumption. JAMA. 1986;256:484–90.

    Article  PubMed  CAS  Google Scholar 

  18. Mintz ED, Weber JT, Guris D. An outbreak of Brainerd diarrhea among travelers to the Galapagos Islands. J Infect Dis. 1998;177:1041.

    Article  PubMed  CAS  Google Scholar 

  19. • Hansen R, Thomson EM, El-Omar GL, et al. The role of infection in the aetiology of inflammatory bowel disease. J Gastroenterol. 2010;45:266–76. This review highlights the current state of the art with respect to infection as a viable candidate for pathogenesis of inflammatory bowel disease.

  20. • Green PH, Cellier C. Celiac disease. N Engl J Med. 2007;357(17):1731–43. An excellent review of celiac disease by one of the foremost researchers and clinicians involved in the care of patients with tlhis disorder, highlighting its epidemiology and possible contribution as a cause of previously undiagnosed gastrointestinal symptoms.

  21. Fasano A, Berti I, Gerarduzzi T, et al. Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study. Arch Intern Med. 2003;163(3):286–92.

    Article  PubMed  Google Scholar 

  22. Rubio-Tapia A, Kyle RA, Kaplan EL, et al. Increased prevalence and mortality in undiagnosed celiac disease. Gastroenterology. 2009;137(1):88–93.

    Article  PubMed  Google Scholar 

  23. Hadithi M, von Blomberg BM, Crusius JB, et al. Accuracy of serologic tests and HLA-DQ typing for diagnosing celiac disease. Ann Intern Med. 2007;147:294.

    Article  PubMed  Google Scholar 

  24. • Carroccio A, Mansueto P, Iacono G, et al. Non-celiac wheat sensitivity diagnosed by double-blind placebo-controlled challenge: exploring a new clinical entity. Am J Gastroenterol. 2012;107:1898. A double-blind placebo-controlled challenge study of a newly described clinical entity, non-celiac wheat sensitivity, which is being increasingly diagnosed and should be considered in this population as well.

  25. Sanders DS, Aziz I. Non-celiac wheat sensitivity: separating the wheat from the chat! Am J Gastroenterol. 2012;107:1908.

    Article  PubMed  Google Scholar 

  26. Biesiekierski JR, Newnham ED, Irving PM, et al. Gluten causes gastrointestinal symptoms in subjects without celiac disease: a double-blind randomized placebo-controlled trial. Am J Gastroenterol. 2011;106:508.

    Article  PubMed  CAS  Google Scholar 

  27. Harries AD, Myers B, Cook GC. Inflammatory bowel disease: a common cause of bloody diarrhea in visitors to the tropics. BMJ. 1985;291:1686–7.

    Article  PubMed  CAS  Google Scholar 

  28. Hotte NSC, Salim SY, Tso RH, et al. Patients with Inflammatory Bowel Disease Exhibit Dysregulated Responses to Microbial DNA. PLos ONE 7 (5): e37932.

  29. Case Records of the Massachusetts General Hospital. Case 29–1992. N Engl J Med. 1992;91:182–91.

    Google Scholar 

  30. Taylor DN, Connor BA, Shlim DR. Chronic Diarrhea in the Returned Traveler. Med Clin North Am. 1999;83(4):1033–52.

    PubMed  CAS  Google Scholar 

  31. Connor BA. Sequelae of traveler's diarrhea: focus on postinfectious irritable bowel syndrome. Clin Infect Dis. 2005;41 Suppl 8:S577–86.

    Article  PubMed  Google Scholar 

  32. Stewart GT. Post-Dysenteric Colitis BMJ. 1950; 405–409.

  33. Spiller R. Irritable Bowel Syndrome. Br Med Bull. 2005;72(1):15–29.

    Article  PubMed  Google Scholar 

  34. Borgaonkar MR, Ford DC, Marshall JK, et al. The incidence of irritable bowel syndrome among community subjects with previous acute enteric infection. Dig Dis Sci. 2006;51:1026–32.

    Article  PubMed  Google Scholar 

  35. McKendrick MW, Read NW. Irritable bowel syndrome–post salmonella infection. J Infect. 1994;29:1–3.

    Article  PubMed  CAS  Google Scholar 

  36. • Spiller R, Garsed K. Postinfectious irritable bowel syndrome. Gastroenterology. 2009;136:1979–88. An excellent overview of the current state of knowledge of post-infectious irritable bowel syndrome with respect to its clinical presentation and pathogenesis.

  37. Okhuysen PC, Jiang ZD, Carlin L, et al. Post-diarrhea chronic intestinal symptoms and irritable bowel syndrome in North American travelers to Mexico. Am J Gastroenterol. 2004;99:1774–8.

    Article  PubMed  Google Scholar 

  38. Ilnyckyj A, Balachandra B, Elliott L, et al. Post-traveler's diarrhea irritable bowel syndrome: a prospective study. Am J Gastroenterol. 2003;98:596–9.

    Article  PubMed  Google Scholar 

  39. Rodriguez LA, Ruigomez A. Increased risk of irritable bowel syndrome after bacterial gastroenteritis: cohort study. BMJ. 1999;318:565–6.

    Article  PubMed  CAS  Google Scholar 

  40. Parry SD, Stansfield R, Jelley D, et al. Does bacterial gastroenteritis predispose people to functional gastrointestinal disorders? A prospective, community-based, case–control study. Am J Gastroenterol. 2003;98:1970–5.

    PubMed  Google Scholar 

  41. • Trivedi KH, Schlett CD, Tribble DR, et al. The impact of post-infectious functional gastrointestinal disorders and symptoms on the health-related quality of life of US military personnel returning from deployment to the Middle East. Dig Dis Sci. 2011;56(12):3602–9. One of the first studies looking at the impact of post-infectious functional disorders including irritable bowel syndrome in a specific group of travelers, i.e. military personnel, and the contribution of antecedent travelers' diarrhea in this population.

  42. Stermer E, Lubezky A, Potasman I, et al. Is traveler's diarrhea a significant risk factor for the development of irritable bowel syndrome? A prospective study. Clin Infect Dis. 2006;43:898–901.

    Article  PubMed  Google Scholar 

  43. Gwee KA, Collins SM, Read NW, et al. Increased rectal mucosal expression of interleukin 1ß in recently acquired post-infectious irritable bowel syndrome. Gut. 2003;52:523–6.

    Article  PubMed  CAS  Google Scholar 

  44. Spiller RC, Jenkins D, Thornley JP, et al. Increased rectal mucosal enteroendocrine cells, T lymphocytes, and increased gut permeability following acute Campylobacter enteritis and in post-dysenteric irritable bowel syndrome. Gut. 2000;47:804–11.

    Article  PubMed  CAS  Google Scholar 

  45. Dunlop S, Jenkins D, Neal K, Spiller R. Relative importance of enterochromaffin cell hyperplasia, anxiety, and depression in postinfectious IBS. Gastroenterology. 2003;125:1651–9.

    Article  PubMed  Google Scholar 

  46. Gwee KA, Graham JC, McKendrick MW, et al. Psychometric scores and persistence of irritable bowel after infectious diarrhoea. Lancet. 1996;347:150–3.

    Article  PubMed  CAS  Google Scholar 

  47. Gwee K-A, Leong Y-L, Graham C, et al. The role of psychological and biological factors in postinfective gut dysfunction. Gut. 1999;44:400–6.

    Article  PubMed  CAS  Google Scholar 

  48. Thabane M, Kottachchi DT, Marshall JK. Systematic review and meta-analysis: the incidence and prognosis of post-infectious irritable bowel syndrome. Aliment Pharmacol Ther. 2007;26:535–44.

    Article  PubMed  CAS  Google Scholar 

  49. Parry SD, Barton JR, Welfare MR. Factors associated with the development of post-infectious functional gastrointestinal diseases: does smoking play a role? Eur J Gastroenterol Hepatol. 2005;17:1071–5.

    Article  PubMed  Google Scholar 

  50. Neal KR, Barker L, Spiller RC. Prognosis in post-infective irritable bowel syndrome: a six year follow up study. Gut. 2002;51:410–3.

    Article  PubMed  CAS  Google Scholar 

  51. van der Veek PPJ, van den Berg M, de Kroon YE, et al. Role of tumor necrosis factor-alpha and interleukin-10 gene polymorphisms in irritable bowel syndrome. Am J Gastroenterol. 2005;100:2510–6.

    Article  PubMed  Google Scholar 

  52. Gonsalkorale WM, Perrey C, Pravica V, et al. Interleukin 10 genotypes in irritable bowel syndrome: evidence for an inflammatory component? Gut. 2003;52:91–3.

    Article  PubMed  CAS  Google Scholar 

  53. Thabane M, Marshall JK. Post-infectious irritable bowel syndrome. World J Gastroenterol. 2009;15:3591–6.

    Article  PubMed  Google Scholar 

  54. Pimentel M, Chatterjee S, Chang C, et al. A new rat model links two contemporary theories in irritable bowel syndrome. Dig Dis Sci. 2008;53:982–9.

    Article  PubMed  Google Scholar 

  55. Jee SR, Morales W, Low K, et al. ICC density predicts bacterial overgrowth in a rat model of post-infectious IBS. World J Gastroenterol. 2010;16:3680–6.

    Article  PubMed  Google Scholar 

  56. Wang LH, Fang XC, Pan GZ. Bacillary dysentery as a causative factor of irritable bowel syndrome and its pathogenesis. Gut. 2004;53:1096–101.

    Article  PubMed  CAS  Google Scholar 

  57. Spiller RC. Postinfectious irritable bowel syndrome. Gastroenterology. 2003;124:1662–71.

    Article  PubMed  Google Scholar 

  58. Spiller RC. Role of infection in irritable bowel syndrome. J Gastroenterol. 2007;42 Suppl 17:41–7.

    Article  PubMed  Google Scholar 

  59. Lin HC. Small intestinal bacterial overgrowth: a framework for understanding rritable bowel syndrome. JAMA. 2004;292:852–8.

    Article  PubMed  CAS  Google Scholar 

  60. Pimentel M, Park S, Kong Y, et al. Rifaximin, a non-absorbable antibiotic improves the symptoms of irritable bowel syndrome: A double-blind randomized controlled study. Am J Gastroenterol. 2005;100:S321–45.

    Article  Google Scholar 

  61. • Pimentel M, Lembo A, Chey WD, et al. Rifaximin therapy for patients with irritable bowel syndrome without constipation. N Engl J Med. 2011;364:22–32. This study is significant because it suggests that symptomatic relief is possible in patients with PI-IBS by eradicating small intestinal bacterial overgrowth, a purported consequence of disordered motility related to traveler's diarrhea.

    Google Scholar 

  62. Pimentel M, Morales W, Lezcano S, et al. Low-Dose Nocturnal Tegaserod or Erythromycin Delays Symptom Recurrence After Treatment of Irritable Bowel Syndrrome Based on Presumed Bacterial Overgrowth. Gastroenterol Hepatol. 2009;5(6):435–42.

    Google Scholar 

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Conflict of Interest

Bradley A. Connor declares that he has no conflict of interest.

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  1. Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical College, 50 East 69th Street, New York, NY, 10021, USA

    Bradley A. Connor

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Correspondence to Bradley A. Connor.

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Connor, B.A. Chronic Diarrhea in Travelers. Curr Infect Dis Rep 15, 203–210 (2013). https://doi.org/10.1007/s11908-013-0328-2

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  • DOI: https://doi.org/10.1007/s11908-013-0328-2

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