Fly Well

The beast with many names

August 1, 2011

SackierMontezuma’s Revenge is a politically incorrect phrase, but (a) nothing political is correct and (b) you immediately know what I mean: Roman Runs, Caribbean Calypso, Traveler’s Diarrhea (TD). Leaving America, aboard your aircraft or the airlines, you are not alone. Inside your belly are gazillions of friendly bugs who call your colon “home.” As one of 100,000,000 people trekking to warm, lesser developed climates your gut is exposed to new bacteria and other organisms, hostile invaders helping Montezuma exert his wicked revenge. TD is where one passes at least three unformed stools/day indicating the intestines now host the Symptom Superbowl—nausea, vomiting, fever, and cramps.

The most common culprits have fancy Latin names; E.coli (frequently induces food-borne illness), Shigella, Salmonella, and Campylobacter. Norovirus causing 80 percent of “cruise ship TD,” is nasty and also afflicts those on long flights. If one passenger makes frequent, green-faced restroom visits, use a different loo, as using contaminated toilets may lead to infection.

About 40 to 50 million suffer TD consequences every year, more commonly in tropical or semi-tropical locales such as Haiti, Dominican Republic, southern Asia, and Africa, and more so during rainy season. Other Caribbean islands and China and Russia carry a 15-percent risk. Given that the problem is caused by unfamiliar bacteria entering your body, folks traveling to the United States from high-risk zones can also succumb to the Washington Waltz or Tampa Tango (as a Haitian may call it).

Industrialized westerners are exposed journeying to lesser-developed zones, but even visiting posh western European countries can induce TD if your gut meets new bugs. Returning to remote locales might protect you from a second episode. Youngsters suffer greater risk because of their more fragile physiology and because they like to pop things into their mouths. Adolescents, with their huge appetites, failure to take advice, no sense of mortality, and willingness to try “street food” are also at increased risk. Although there are genetic risk factors explaining why one family member gets sick and others do not, dietary indiscretions are responsible for much of the grief TD causes. Avoid the water and eating partial or totally uncooked foods, or those potentially washed in contaminated water such as salads or soft fruits. If you have chronic heartburn (see “ Fly Well: Heartburn and the Art of Aircraft MaintenanceAOPA Pilot, March 2011) and use daily “PPI” drugs such as omeprazole; TD may be more likely as these medicines reduce stomach secretion.

Diagnosis is usually fairly straight-forward and other than symptoms and a clinical examination, stool samples may be checked by the lab to identify the responsible organism or to have a peek for parasites or their eggs under the microscope.

The likely course is 24 hours of abject misery and a ruined trip; rest is key, maintaining hydration with an electrolyte solution. If you cannot retain liquid, seek medical attention to provide intravenous fluids, especially in a hot climate where dehydration can set in earlier. One dangerous sequel is called “Hemolytic Uremic Syndrome” where kidney damage can even be fatal. If not making a rapid recovery, get to a doctor. The use of antibiotics to suppress an attack still provokes controversy and these drugs are also sometimes prescribed to head off TD at the pass. The most commonly used are fluoroquinolone (ciprofloxacin or levofloxacin), rifamaxin (Xifaxan), and azithromycin (Zithromax). Various medicines reduce diarrhea episodes, such as loperamide or, when traveling outside the United States, kaolin and morphine, which also address the pain. If TD is accompanied by fever or blood in the stool, do not take such meds as they increase how long the bugs are in contact with the gut.

AOPA Aviation Summit

Join Dr. Jonathan M. Sackier at AOPA Aviation Summit, September 22 through 24, in Hartford, Connecticut, for health-related discussions.

Chronic complications are rare but include persistent diarrhea, bloating, constipation, and pain. Younger women are especially prone to develop irritable bowel syndrome, affecting five to 10 percent of patients, more likely if TD was characterized by fever or weight loss and a history of depression or anxiety.

Before traveling overseas, speak to your doctor or local travel clinic and discuss your risk factors. Decide what you will eat and drink and stick to it. Consider whether you are a candidate for prophylactic antibiotics and also look into other options; bismuth subsalicylate is quite effective and some swear by herbal remedies like probiotics (Lactobacillus GG and Saccharomyces boulardii) or eating oodles of “live” yogurt. The recommendation to only consume alcohol, while good for a giggle, is not sensible. Alcohol induces dehydration, and chronic inebriation is not wise, especially for pilots.

Maybe because I am interested in the bowels, am English, or just plain odd, I will provide a prize to the person who comes up with the best TD epithet I have not heard!

Email the author at jonathan.sackier@aopa.org.