Being politically correct is frowned on by some these days. Others go above and beyond to avoid being politically INcorrect, occasionally to the extent of obscuring the meaning of their intent. I don’t know where the term Montezuma’s Revenge falls in this spectrum, but unfortunately, I was motivated to write about it due to recent events.

For a history of the name, check this out: Why Is Travelers’ Diarrhea Called Montezuma’s Revenge? Montezuma’s Revenge is also known by other less-than-politically-correct names, such as Turkey Trots and Bali Belly. Yet, it is more clearly understood as Traveler’s Diarrhea (TD). No doubt those reading a blog on aging have experienced this in their life.

On a recent trip to Costa Rica, I traveled with a group of people in which several (yours truly included) suffered gut issues. Being a country with universal health care, several people on our trip were able to speak with a pharmacist easily and inexpensively purchase medicinal remedies. Still, accessible health care or not, no one wants to contend with TD while traveling. Further, it is not unheard of in the states either.

Why Do We Contract TD?

The surprising fact is that epidemiology shows approximately 30-50% of international travelers visiting developing countries acquire Traveler’s Diarrhea (TD) each year. For U.S. travelers, it can exceed 60% when trekking to Asia, Middle East or Africa as well as Latin, Central and South America. Risk is less in other places. Those from different countries may experience something similar in the U.S. but generally due to a change in diet, not sanitation. Also U.S. hikers and campers can demonstrate a subtype of TD known as “wilderness diarrhea” most often developed from protozoans, such as the infamous Giardia we all use to dread in NY’s Adirondacks.

While protozoans and viruses account for some TD, the vast majority (probably more than 80%) are from bacteria, such as E.Coli. The source is contaminated food or water for which the traveler has no, or limited, immunity from the local pathogens.

Seniors have additional risks (although young adults are more prone to TD due to less sophisticated immunity). These risks to seniors include immunosuppression issues, inflammatory bowel disease, liver, heart or kidney problems, diabetes, and certain meds (like H2 blockers or even antacids). Those with these complications are not indubitably bound to contract TD, but encouraged to take extra reasonable precautions.

It’s rarely listed in the literature, but I do wonder about a cleaning practice. Many other counties (due to strain on sanitation systems) strongly request that all toilet paper waste be placed in a container, not the commode. I ponder whether unaccustomed Americans may suffer additional contamination this way. (Conversely, I admit it has value to the water and public sanitation systems.)

How do I know I have TD?

The good news is that most TD is mild and doesn’t last long (2-5 days on average). Yes, it can be severe and result in hospitalization but that is truly rare (less than 3%) and even less if dehydration is avoided.

Regarding the most common Bacterial TD, it begins abruptly (as opposed to some parasitic types that can incubate for 7-14 days). As the name ‘Trots’ implies, the traveler can experience urgent needs to use the bathroom many times a day and may suffer multiple loose or watery bowel movements. One of our group had 8 such events in one day, and another advanced from a mild to moderate case.

Simple abdominal cramping, bloating and running to the nearest facility is common. Rarer symptoms can include fever, malaise and decreased appetite. I admit I might have been better off with some reduced appetite as each meal seemed to trigger more mild suffering. (Some of us are slow learners.) Nausea and vomiting are not as common but still occasionally present in mild TD.

If diarrhea progresses it can turn into dysentery, a harsher type of diarrhea, also with nausea and vomiting. Blood may be noticed in the stool, although often times with mild cases this is surface blood from external hemorrhoids affected by the constant or harsh wiping away after the diarrhea bout. High fever with severe abdominal pain, sudden weakness and fatigue accompanied by clear blood or mucus in the stool suggests a serious condition. These situations should compel one to consider exigent medical care.

Prevention in U.S. or Abroad

Not all preventative tips against TD are reasonable when away from home. Still, it is good to consider pre-emptive strikes whether traveling abroad or even to a different area of the U.S.

Perhaps number one for the traveler is frequent (good) hand washing. Obviously, it doesn’t help things you ingest, but it’s a start in the right direction.

Second on my list is to stay hydrated. We will visit that again under treatments, but it’s vital for prevention as well.

Safe Water

• Often people equate safe water to bottled water. While bottled water is now available in even the most remote destinations, my tour company was not offering bottled water (to avoid plastic pollution). They encouraged the use of water from filter machines in the hotels. This CAN be sufficient, as long as the machines are clean.
• Treating your own water. Boiling is often considered the most effective method since organisms are usually killed in seconds at temperatures of 55–70 C (131–158 F). However, it is not always easy to boil water in your room far away. On my trip, we didn’t always have a ceramic cup in the room, let alone a way to boil it. You can also use chemical treatments using chlorine bleach (being careful of using only soupcon amounts of a few drops/gallon), iodine (being ready for the taste) or commerical tablets. UV light can be somewhat effective but only if water is clear and not turbid or muddy (turbid water can keep microorganisms hidden from the needed exposure). UV, if done correctly, is quicker than boiling and doesn’t alter the taste.
• In foreign counties, in restaurants or with street vendors make sure ‘bottled’ water is unsealed in your presence. Shifty vendors have been known to fill empty bottles with the very untreated tap water you are trying to avoid.
• Carbonated beverages (seltzer, club, etc.) are usually a prudent choice as the carbonation can’t be simulated. They often contain healthful salts as well.
• Make sure you are served HOT tea or coffee and not just warm or lightly heated.
• Avoid using ice in drinks (sad to say). You may be uncertain if they were made with safe water.
  On our trip we considered it a special treat to be given ice cubes. Oops. And we knew better. But I was thrilled to be served a couple large ice cubes (almost ceremonial style) in a local pub. Luckily, the ice was placed in a glass containing a fairly strong alcohol, which may have killed any bacteria.
• Use bottled or filtered water for brushing teeth and rinsing mouth.

Safe Food

• One common rule of thumb is “Cook it, Peel it, Boil it, or Forget it.” As with numerous suggestions, I question how reasonable this can be when traveling away from home, especially traveling with a group, and when you hope to experience new cultural foods.
• Avoid lettuce, green salads, or fixing of raw veggies. Often, while it’s washed, it is not always done so with safe water that the traveler is used to. If it’s a boring, familiar offering, forego it.
• Concentrate on fruits (or vegetables) that have skins to remove. This too can be difficult if someone else (possibly with contaminated hands) is doing the peeling, but it is more likely safe than eating skins. If you can peel it yourself – good deal.
  Either way, traveling to a place like Costa Rica with mangos and pineapples and papayas that actually taste divine, it would be beyond my self-control to pass them up.
• Skip buffets or street vendors that have food that’s been sitting out. Some buffets keep the food in hot chafing dishes which is a plus as it’s advantageous to eat well-cooked, very hot meals. Again, not always your call in a group or tour setting.
• Avoid milk or dairy products (even mayonnaise) that is unpasteurized.
• Avoid raw or under cooked meat or seafood.
  That sounds easy, right? What about my multiple orders of fish ceviche? The acidity of citrus marinade in ceviche alters the fish to look and feel cooked but it’s not with heat. It’s considered safe as long as the fish is ‘sashimi-grade’ and refrigeration has been adequate. For a pescatarian, in a country known for fresh ocean catches, this is another luxury difficult to shun.

Alternative Remedies for TD

Most of the natural or alternative remedies touted as treatment for TD are not sufficient alone – at least not for established cases with diarrhea. Still, they offer some minor relief in alleviating symptoms and for prevention. They are not all ‘created equal.’ The one important exception to the limited-benefit category is electrolytes or oral rehydration solutions, which I’ll proceed to momentarily.

Helpful natural approaches. The couple natural solutions that have either research or long historical value include:

• BRAT diet – gentle on the stomach and in mild cases can help firm stools. BRAT stands for: Bananas, Rice, Applesauce and Toast.
• Activated Charcoal – something I never travel without, due to its first-rate effect on gas, can help absorb pathogens in the gut. However, while it temporarily eases stomach discomfort it should never be taken for long periods of time (more than a couple days) since while it absorbs the toxins and pathogens, it also absorbs vitamins, nutrients or medications.

Secondary remedies that may minimally help prevent TD by strengthening the traveler’s gut are less likely to soothe or cure an existing case of TD. These include:

• Probiotics – help restore balance of the good bacteria in the gut. But while proponents feel strongly in support, research has been weak demonstrating any real effect on established TD.
• Ginger – known for soothing nausea, can be taken either as tea, capsule or fresh in food or drink.
• Chamomile tea – thought to sooth intestinal inflammation.
• Peppermint tea – thought to have antispasmodic elements relieving cramps.
• Garlic – known for antimicrobial properties is helpful but probably not strong enough to repair or reduce TD.
• Apple Cider Vinegar – similarly known for antibacterial properties is helpful but not strong enough to repair or reduce TD.

Electrolytes & Hydration for TD

As I mentioned above, oral rehydration solutions are vital to TD treatment and can make the difference between a few days of a mild case versus hospitalization if dehydration and lack of nutrients bring you down. It’s therefore of the highest priority to consume adequate fluids.

Some experts will also counsel against drinking any alcoholic or caffeinated liquids to avoid the dehydration. Tricky if you are on a lovely vacation and want to enjoy a special drink or two, but worth the sacrifice if the trots are calling. As a substitute to alcohol, our guide would join us in the festivities with a salt-rimmed glass of club soda and lemon juice.

One way to replace minerals lost through diarrhea is the use of ORS packets (Oral Rehydration Salts) promoted by the World Health Organization (the U.S. is no longer a WHO member). These packets are available at stores and pharmacies around the world, as they were in Costa Rica. You still have the problem of mixing the powder as needed with either bottled or boiled water. Yet, when traveling it’s at least easier than lugging small bottles of Gatorade around. You drink it throughout the day.

If you are in a convenient situation, you can make these solutions yourself. I had a slightly different hydration formula in my book 120 Years and Holding, but this is easy and suitable:

• 3/4 teaspoon table salt
• 2 tablespoons sugar
• 1 quart bottled or boiled water

Along with ORS powder packets, you can also find liquid drops of electrolyte products. Other suggestions are carbonated mineral water (which tends to have salts), eating salted crackers or drinking Rice Water, a source of high electrolyte content. Somewhere along my research readings I saw that drinking mushroom coffee might ease symptoms. I’m skeptical, but at least it is more liquid and I’ve actually tried it (better than it sounds).

TIP. My favorite thing learned on this past trip is that there are Electrolyte Gummies. Was I the last to know? I was not familiar with these products, but one of our traveling companions had brought some along. What a great and convenient idea. Like other products, they vary a great deal. If you decide to purchase some for your next trip, search for those that contain as many of the essential minerals as possible. Look for sodium, potassium, magnesium and calcium. Hmmm, Electrolyte Gummies – just yummy.

Seniors – Treating Your TD with Meds

Mild Diarrhea Frequency of loose stools with few other symptoms than mild cramping or distress.  Some malaise. It’s uncomfortable, but tolerable, and you are basically able to carry on with activities.

Pepto-Bismol (preferably ‘Pepto-Bismol Diarrhea’) Pepto Diarrhea, which contains the same active ingredient as Pepto Bismol (bismuth subsalicylate), has a triple-action formula, coating your stomach, drying stools and killing the bacteria that causes most diarrhea. This is my preferred 1st choice over Imodium. Original Pepto Bismol is effective for nausea and digestive disorders, but Pepto-Diarrhea is specifically helpful for TD. It may be harder to find ‘chewables’ in the Pepto-Diarrhea version, but chewables are easier for traveling. Four times a day is typical recommendation, but never more than 3 weeks.  (Avoid if aspirin allergy, kidney disease or gout. Also, not for children or pregnant women.) *

Moderate Diarrhea Frequent loose stools with mild/moderate cramps and nausea or vomiting. Distressing and may interfere with planned activities.

Imodium (Loperamide) should not be used for the mildest cases.  It is an antimotility drug (as is diphenoxylate) and will slow down transit time in the gut (frankly meaning, the passage of poop.)  Because it slows the frequency of stools it delays expulsion of the causative organisms. Quoting our guide: “It’s like a cork.” It’s not recommended to take for more than 2-3 days or if you have a high fever, dehydration or bloody diarrhea (it’s not for infants either, or children under two years).

Severe Diarrhea Cramps, nausea, vomiting, bloody stools, high fever, dehydration and frequent, severe loose stools.  Weakness. Often prevents taking part in planned activities. Medical help or medications are likely advised

Antibiotics, such as Azithromycin or Cipro.  Some antibiotics allow you to continue to take Imodium, if necessary, without contraindication.  Usually only 1-3 tablets are recommended. [Antibiotics don’t help if the cause is viral.] Antibiotics are NOT the first choice of treatment if they can be avoided due to the risk of allergy, adverse reactions, and possible decrease in effectiveness if needed later.  They are also related to certain infections and colitis. Particular antibiotics, known as Quinolone antibiotics, should not be taken with Pepto-Bismol (or other bismuth subsalicylate products.)

*Reminder: all medications, whether OTC or not, can have side effects, especially if taken too long.

Final Thought

I rather wish I had written this blog before my trip, as I would have been reminded of better habits and solutions. Luckily, I had a good time and enjoyed the cultural flavors of all sorts.

When we are traveling to places with foods, climates, and cleaning practices that are very different from our home country, or camping out, or visiting other areas of the states, it can increase our risk for traveler’s diarrhea.

No matter the area or country, we can eat or drink foods or beverages containing bacteria, viruses, or parasites that can make us sick. Fortunately, the usual situation is that the condition gets better within a few days even without treatment.

However, some of the preventative measures and treatments mentioned above are good to have on hand if your symptoms remind you that you’re suffering the Aztec ruler’s curse.

Why is it called “Revenge?”
Because after 500 years, Montezuma finally found a way
to make the tourists run.

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Friends, some of you may laugh at the fact that I had a misspelling in my first draft that listed the signs of severe diarrhea as “cramps, nausea and voting.”  Caring about voting as much as I do, this was perhaps a ‘Freudian slip’ of our times.

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Title picture – Stone Image by freepik

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