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Why travel screws with your stomach & how to help.

by Colleen_Stinchcombe

Colleen_Stinchcombe

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“In general, I think the most common things that people get are upset stomach, bloated and constipation,” she says. Diarrhea can also occur — you may have heard of traveler’s diarrhea — but it’s usually related to an infection rather than general traveling.

Why does this happen?

“That in and of itself can just change the whole dynamic of the GI tract,” she says. Travel, especially by airplane, can also lead people to get dehydrated (I mean, who hasn’t sipped water sparingly so they don’t have to climb over their seat mate ask to get up for the lavatory?), which can lead to constipation.

These two things — a change in schedule and dehydration — are the main culprits, according to Cohen. It certainly doesn’t help that people who travel are often eating differently than they do at home. Whether it’s eating more carb- and fat-heavy foods or eating larger portions than normal, our gut is thrown for a bit of a loop. That can lead to constipation and other GI upset too. Cohen adds, “It kind of shifts the system.”

Sometimes you can experience what’s called traveler’s diarrhea, which reports say affects 40 to 60 percent of travelers.  Some cases are due to bacteria from food or water that causes illness, and may take a few days of your trip to recover from.

What can you do?

So, are your vacations doomed to gastrointestinal distress forever? Not necessarily. Cohen says there are several steps you can take to relieve the most common symptoms.

First, it must be said that if you’re already on a regimen to help alleviate constipation and bloating at home, continue that when you travel, she said. “You shouldn’t just stop because you’re going away,” she notes.

More: Can Using a Fitbit Have a Long-Term Impact on Your Health?

If you don’t have gut issues at home but do when you travel, Cohen recommends getting ahead of the issue. Before, during and after the trip, drink more water and eat more fiber-rich fruits and vegetables. Apples, bananas, and nut bars with good fiber content can make great travel snacks, she says. If you mainly struggle with bloating, try not to eat larger portions than usual at mealtimes. If you’re still having issues, look for herbal options. “Peppermint, ginger, [and] fennel are helpful for bloating,” she says. Look for foods or drinks that contain them.

Exercise can also be key, especially if you’re already active at home. “Just like your heart needs exercise, your colon needs exercise,” Cohen explains. Between long flights or car rides and a packed itinerary, it can be easy to let movement go by the wayside. But you don’t have to do an intense workout routine to help relieve symptoms, she adds. Even a long walk can help to get the colon moving.

More: Self-Care Retreats to Help You Recharge

Still feeling uncomfortable? “If they know they get really constipated and diet isn’t enough, then sometimes I make sure they bring a gentle over-the-counter either fiber or laxative to have in hand in case it starts happening,” Cohen says. She recommends that her patients take a fiber assist or gentle laxative as soon as they start feeling symptoms rather than waiting until the problem is making them seriously uncomfortable.

If you’re prone to get traveler’s diarrhea, or are headed to an area where this can be common (such as Latin America, Southeast Asia, and the Caribbean ), it would benefit you to take a probiotic before and during your trip, and drink bottled water once you get to your destination as much as possible.

Ultimately, you should feel free to enjoy your wanderlust to the fullest, delicious local food included. Just give a little love to your gut along the way.

Before you go, check out these ways to stay hydrated during your trip:

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Nothing brings a vacation to a screeching halt faster than a travel-borne stomach illness. Both the stress of traveling and changes to your regular diet play havoc on your digestive system and can bring on a myriad of stomach-related issues. Let’s explore some simple steps you can take to avoid travel stomach and arm you with proven tips to treat digestive problems if they do hit.

Be Prepared

When you travel to places where the climate or hygienic practices are not what your body is used to, or you want to sample the local cuisine, you have an increased risk of developing unpleasant digestive issues. As part of trip planning, the CDC encourages travelers to create a travel health kit for common medical emergencies. You should pack it in your carry-on bag and keep it with you all of the time. When it comes to traveler’s stomach, these items include oral rehydration salts for fluid replacement and OTC medications like Pepto Bismol or Imodium. You should also consult a doctor before your trip to get a prescription for an antibiotic you can take in case of diarrhea. Make sure you get guidance on when you should and should not take the medication. It could do more harm than good. You can also buy a travel-ready first-aid kit from Amazon for about $15 if you don't want to build one from scratch.

Some peoples get a traveler’s tummy because of the stress of the trip or a change in their routine or diet. But the most common culprit comes from an infectious agent like bacteria or parasites ingested after eating tainted food or drinking water. You can’t take your cue from locals who eat and drink because they have become accustomed to the bacteria and have built up an immunity to them.

How to Avoid Traveler's Stomach

There are simple ways to prevent traveler's tummy. The best way is to avoid exposure to the germs that cause this buzzkill of an illness. Here are some tips from the CDC and WHO that will help you avoid traveler's stomach all together:

·        Drink only beverages from sealed containers and pour them into a clean glass.

·        Don’t use ice cubes unless you can trust they came from clean water.

·        Only eat foods that are fully cooked and served hot.

·        Eat raw fruits and vegetables only if you can wash and peel them.

·        Avoid unpasteurized dairy products, including ice cream.

·        Wash your hands religiously with soap and water. If you can’t, use an alcohol-based hand sanitizer.

·        Keep your hands away from your mouth, eyes, and nose. This also helps you from getting a cold or the flu.

·        Live by this mantra—hydrate, hydrate, hydrate!

Proven Treatment

Even if you faithfully follow the steps to avoid digestive issues, you may still come down with the traveler’s stomach. It usually starts with a sudden attack of diarrhea with cramps, nausea, and/or vomiting (you may or may not have a fever). In most cases, it clears up on its own in a couple of days. Once you have identified your symptoms as a traveler’s stomach, you’ll need to replace the massive amounts of fluid and electrolytes you lost.

Staying hydrated is a crucial part of staying healthy while treating your stomach issues. Taking the anti-motility agents can help cut down on the trips to the bathroom, but they can also aggravate your feelings of dehydration, so again (it can’t be stressed enough), drinking loads of water is key to treating traveler’s tummy.

Here are the essential steps in treating traveler’s diarrhea:

·        Replace fluids with water and by using an oral rehydration solution . Avoid caffeinated drinks as well as alcohol.

·        Take over the counter anti-motility drugs (the most common are Pepto Bismol and Imodium)

·        Ensure you’re rested. Being stronger helps you battle any digestive issues. Taking a magnesium glycinate supplement can improve jet lag and promote relaxation and sleep while traveling.

·        If recommended by a health care provider, take a regimen of antibiotics. Two common medicines are ciprofloxacin and norfloxacin.

Following this treatment advice can help resolve symptoms within just a few days, so you can get back to enjoying your trip.

When to Seek Medical Help

If your condition is accompanied by a fever or tiredness or diarrhea persists for more than a couple of days, you might want to get some medical attention. Here are signs that you need to see a medical professional:

·        You can’t keep down light foods or liquids and have frequent vomiting.

·        Your symptoms linger for more than 48 hours.

·        You have a fever of over 102 F.

·        You have severe abdominal pain.

·        You have blood or mucus in your stool.

Note: This article offers only information and is not a substitute for the advice of a medical professional. If in doubt, always err on the side of caution.

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4 Common Gut Problems You Face When You Travel—and How to Fix Them

Three days into a dream vacation, and your GI tract has turned against you. What gives? It’s not bad timing; it’s travel that’s to blame, says Dawn Blatner, RDN, author of The Superfood Swap . “Stomach issues tend to happen any time we’re out of our routine,” she says. Which, unfortunately, means your yoga retreat and backpacking adventure  are prime targets for an intestinal temper tantrum.

But rather than spend the rest of your vacay holed up in your hotel bathroom, you can get your GI tract back on track and go see the sights—without forgoing the local flavor.

Keep reading for the quick fixes you need for the most common traveler tummy woes.

If you can’t go...swap that pina colada for a water bottle and a walk

Sipping frozen slushies by the pool or grapes at the vineyard is fine (in moderation!), as long as you’re still drinking enough water. If not, you could wind up dehydrated (and…cue the constipation). “Almost everyone gets dehydrated when they travel,” says Blatner, both because frilly drinks just seem more fun than downing plain water and because we’re not in our usual water-drinking routine (like making three trips to the water cooler to break up the afternoon at work).

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Quick fix: If doubling down on your water intake doesn’t get things moving, try going for a walk. Exercise—even low-impact activities, like yoga and walking— stimulates the gut , which means food has less time to sit in the large intestine, where water gets reabsorbed back into the body, drying out your waste. Gross, but true!

If you have traveler’s trots...focus on fiber

Americans aren’t used to the waterborne bacteria in other countries, so if you’re traveling abroad and diarrhea strikes, a glass of tap water may be the culprit. “But Turista or Traveler’s Diarrhea is really only a condition we get abroad,” says Blatner. “So if it strikes closer to home, it means you’re probably eating too much fat and not enough fiber.” A mega-dose of fat (like having queso fundido instead of your usual quinoa salad for lunch) speeds food through the large intestine, so there’s less time for water to get reabsorbed and your stool stays watery. But fiber slows gastric motility, and will help slow the trots.

Quick fix:   Soluble fiber should be your new BFF throughout the day, but Blatner recommends it especially at breakfast, when your options are probably more basic (and less tempting) anyway. Berries and avocados are both surprisingly high in fiber, and they pair well with fiber-rich oatmeal and whole wheat bread. And for some over-the-counter relief, reach for Imodium or its generic equivalent. “Some people have a more sensitive stomach than others, and you can take Imodium for a really long time without worry,” says Yuri Saito, MD, a professor of gastroenterology at the Mayo Clinic.

If you have bikini bloat...try the "plus one" rule

Okay, you probably haven’t gained 10 pounds within days of stepping off the plane, but the combination of overindulging and dietary changes can be a one-two punch for your waistline. Salty and dairy-rich foods can increase gas and water retention, says Blatner, while feasting with abandon can just make you feel gross. “When we’re on vacation, we tend to throw our usual routine out the window and go for it all,” she says.

Quick fix: If you’re lactose intolerant, know that your enzymes won’t change just because you crossed time zones or zip codes. Stick to your usual dairy avoidance  regimen (or pack the Beano, says Dr. Saito, which has enzymes that break down dairy in the digestive tract so it won’t cause gas, bloating, and diarrhea). And to help rein yourself in without feeling like you’re missing out, employ a “plus one” mentality. “At the start of the meal, ask yourself what you want to add to your entree: a drink, an appetizer, or a dessert,” says Blatner. Noshing on all three will have you loosening your belt by the car ride home, but if you pick just one, you can let loose without feeling like a blimp afterward.

If you're hangry about your options...make a plan!

Maybe you’re looking forward to a six-state road trip , but dread the idea of living on fast food for a week. Or you’re headed to Italy but worry you’ll chase a non-stop carb-fest with a serving of balloon-sized bloat (and more gelato). You could dig your heels into denial and hope that the perfect, healthy choice materializes—but you’re probably setting yourself up for frustration. “Some of the worst choices we make are when we’re starving and don’t have our go-to options available,” says Blatner.

Quick fix: Before you hit the road or the airport, hit the grocery store for some portable snacks. Roast chickpeas, almonds, and low-sodium jerky all get Blatner’s seal of approval—and if you pair those protein-rich eats with a piece of produce, you’ll be satiated for a few hours at least (and can avoid the hotel vending machines entirely). Also, carve out the time to research healthy(ish) eating options. “Your game plan may not be perfect, but planning even one meal a day gives you the freedom to make more important decisions during your adventures,” she says. In other words, less time fretting over where to eat—more time savoring each bite.

And did you know, you actually  can  find nutritious foods at the gas station ? Plus, here's what nutritionists always snack on .

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Traveler’s Diarrhea: How to Protect Yourself

The Editors

We are the editors of SmarterTravel! Together we have appeared in countless travel publications including ABC News, Huffington Post, Travel + Leisure, USA Today, and more. We dedicate our days to creating and producing expert travel content, including packing tips, general travel advice, destination inspiration, and helpful videos. Follow us across social media on YouTube , Pinterest , Facebook , Instagram , and Twitter or drop us a line to say hi at [email protected]!

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It’s probably the most unpleasant minor traveler’s malady. Unfortunately, it’s also probably the most common. Call it what you will — traveler’s tummy, Montezuma’s revenge, the traveler’s trot, the Toltec two-step, Delhi belly, the runs or the commonly accepted TD (for traveler’s diarrhea) — but don’t call it fun. Symptoms include diarrhea, stomach cramps, nausea and vomiting. Further, it can be dangerous, causing severe dehydration, malnutrition or worse.

The Centers for Disease Control and Prevention (CDC) reports that between 30 and 70 percent of international travelers suffer some form of TD. A vaccine against E. coli, the most common cause of traveler’s diarrhea, has been under development for more than a decade now — and there’s no sign that it will be released any time soon. Until then, here are our tips for preventing, identifying and treating traveler’s tummy.

What Causes Traveler’s Diarrhea?

A new diet, dehydration from flying, a change in climate, stress and even lack of sleep can cause simple traveler’s tummy. The most common cause of traveler’s diarrhea is bacteria, particularly E. coli, but many other microbes can lead to intestinal distress.

In most cases, traveler’s tummy is easily treated, a mere inconvenience in your travels. However, more serious ailments are possible, including dysentery, cholera, giardiasis and other intestinal disorders. See below for more on these conditions.

How to Avoid Traveler’s Diarrhea

Skip the ice cubes in your drink, pass on salads or other raw foods in developing countries, and seek out bottled water rather than drinking from the tap. For more tips on avoiding traveler’s diarrhea, read Food Safety: How to Avoid Getting Sick While Traveling and Drinking Water Safety .

Worldwide Risk Levels for Traveler’s Diarrhea

Note that in high-risk areas, it may be all but impossible to avoid some incidence of traveler’s tummy, even if you’re careful about what you eat and drink. Certain risk factors (such as worker hygiene in restaurants) are simply out of your control. Here’s a breakdown of your risks around the world:

High Risk: Most developing countries in Latin America, the Middle East, Africa and Asia

Intermediate Risk: Some Caribbean islands, some countries in Eastern Europe, South Africa, Argentina and Chile

Low Risk: The United States, Canada, Northern and Western Europe, some countries in Eastern Europe (including Poland and Slovenia), New Zealand and Australia

For more details, check out the CDC’s destination-specific health information .

Identifying Traveler’s Diarrhea

As outlined above, symptoms can include diarrhea, stomach cramps, nausea and vomiting. These symptoms can be relatively severe, but should not persist for more than a few days, or become particularly violent. Even simple traveler’s tummy can be life-threatening under some conditions, so consider seeking medical attention if symptoms worsen or continue for more than 48 hours.

Common bacterial diarrhea usually sets in very rapidly and without warning and is not typically accompanied by bloody stools. About 80 to 90 percent of TD is considered bacterial diarrhea, according to the CDC.

There are other, arguably more serious maladies that cause similar or identical symptoms to common traveler’s diarrhea:

Amebiasis (amebic dysentery) : The appearance of blood or mucus in the stool is a sign of potential dysentery. In this case, you should seek medical advice.

Giardiasis : This is a somewhat more complex intestinal disorder that can recur repeatedly for weeks after the conclusion of travel, as the protozoan that causes it has a longer incubation period than most bacteria. Symptoms include diarrhea, nausea, bloating, abdominal cramps and more, and may not appear until a week or two after the protozoan is introduced into your body. If you find yourself having repeated outbreaks of diarrhea even after your trip is over, or if your symptoms persist longer than a few days, seek medical attention.

Cholera : The appearance of severe, watery diarrhea spotted with mucus can be indicative of cholera. Other symptoms might include leg cramps and vomiting. It’s important for cholera sufferers to quickly replace their body’s lost water and salts to prevent dehydration. They may also need medical help.

Other conditions accompanied by fever, lethargy, persistent diarrhea lasting more than 48 hours, or severe diarrhea may require treatment with antibiotics and are cause for medical intervention.

Traveler’s Diarrhea Treatment

Symptoms of traveler’s tummy usually clear up on their own after a day or two. To speed your recovery, you’ll want to alter your diet. Staying hydrated is your first priority. Drink bottled fluids (such as water and Gatorade) and avoid caffeinated drinks such as soda, coffee and tea, as well as alcoholic drinks. Of course, you must use a clean water source. Oral rehydration salts can also help.

The most common treatment for traveler’s diarrhea is the use of bismuth subsalicylate (Pepto-Bismol), or the stronger loperamide (Imodium), but understand that these products merely relieve the symptoms and don’t actually provide a cure. In fact, in severe cases of abdominal distress, the tendency of these treatments to “block up” your digestive system can actually be counterproductive or dangerous.

These products may contain aspirin, and bismuth subsalicylate can cause a blackening of the tongue and stools, and occasionally ringing in the ears. These side effects disappear when treatment is discontinued.

Because most traveler’s diarrhea is caused by bacteria, antibiotics are generally effective. Two of the most common are ciprofloxacin, also known as Cipro, and levofloxacin. Once symptoms relent, you can discontinue taking the antibiotic; doctors indicate that you don’t have to see the treatment through a full cycle as with most antibiotics. If you’re headed to a developing country, you may want to ask your doctor to prescribe you a course of antibiotics to take along just in case.

These treatments are useful in the case of bacterial diarrhea, but not for amebic dysentery, viruses or food toxins. In fact, in these cases, you can make your infection worse. A simple rule: If there is blood in your stool, or if you have a fever, pass on these products and see a doctor.

When to Seek Medical Attention

If there is blood or mucus in your stool If you have a fever If symptoms persist for more than 48 – 72 hours If you cannot keep down light food or liquids

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Preventing Gut Issues When Traveling

For many people, traveling is a fun and exciting way to explore new places. However, for those with gut issues, traveling can be a challenge.

The primary purpose of a vacation should not be to visit your stomach. It should be about exploring your destination, tasting local foods, and spending time with family and friends — not stomach problems.

Sometimes, all of the adjustments that come with traveling may create a perfect storm that wrecks your digestion. This article will provide tips on preventing and managing gut problems when traveling.

Common Stomach Issues Causes

Taking a vacation might result in uncomfortable symptoms for a variety of reasons. Here is a list of frequent stomach problems below.

Over Eating

Traveling implies dining in local restaurants. This might entail eating more sugar, caffeine, and fatty meals than usual, which can alter the equilibrium of bacteria in your gut. Stomach complaints such as bloating, constipation , and diarrhea can result from ingesting too much food or overeating in general. Enduring long periods without food may also irritate your stomach and induce heartburn.

Not Enough Liquids

The first item on your holiday or vacation's to-do list is usually exploring your destination. But don't forget to stay hydrated ! Not drinking enough fluids (water) can slow digestion and result in indigestion and severe, painful stools.

Traveling Stress or Anxiety

Depending on where you are going, shifting time zones can be difficult for your body to adjust. You may eat at different times, sleep later, and rest less than average. These changes can upset your usual digestive routine and result in stomach problems. Heightened stress or social anxieties brought about by a new location can agitate any gastric distress you may experience.

How Can You Avoid Gut Issues When Traveling

Here are some pointers for avoiding stomach problems when traveling.

Drink Plenty Of Water (Liquids)

Water is required for your digestive system to function correctly. Water aids in the breakdown of food, the absorption of necessary nutrients, and the movement of waste throughout your body.

Staying hydrated can help improve stool consistency and frequency, as well as the amount and weight of bowel motions. When traveling, staying hydrated may help you avoid constipation.

Surprisingly, drinking water can help you avoid colon cancer. This is because increased fluid consumption speeds up waste transit through your digestive system, reducing your exposure to carcinogens. At the same time, this isn't travel-specific advice; it's important to remember how important staying hydrated is in your everyday routine!

Fiber-Rich Foods Can Help

Fruits, vegetables, and whole grains rich in fiber can help you digest better and relieve stomach problems. A fiber-rich diet may help prevent constipation and diarrhea by:

• Stool Normalization
• Thickening of the stool
• Bowel Movement Frequency

Fiber can also help with abdominal pain, bloating, and abnormal bowel habits in persons with irritable bowel syndrome. Drinking lots of water can enhance the advantages of a fiber-rich diet.

Remember that when increasing the amount of fiber in your diet, do it gradually. If your body doesn't have enough time to adapt, overeating fiber might cause bloating and discomfort.

Move Around and Staying Active Is Key

Getting to your destination can take a lot of sitting, whether driving or flying. Unfortunately, your digestive system isn't as effective when you aren't active.

Walking, for example, will help increase blood flow in your digestive muscles.

This can cause muscular contractions to move waste through your body and minimize the risk of constipation by stimulating muscle movement.

Staying active physically helps to increase the variety of bacteria in your gut. Having a diverse range of protective bacterial species is beneficial to your health and may help you live longer:

• Inflammation Reduction
• Intestinal barrier restoration
• It helps strengthen the immune system
• Lowers digestive discomfort

Don't feel obligated to go to the hotel gym if exercise isn't your thing. Walking around your destination is a fantastic method to improve your digestive health.

Stress Management

Your body enters a "fight or flight" response when stressed out and emotional. This dampens your immune response and digestion and increases your heart rate, blood pressure, and glucose production.

Chronic stress can cause inflammation and lead to the following problems:

• Abdominal pain
• Constipation

Stress can significantly impact your digestive health if you have a chronic bowel disease such as inflammatory bowel disease (IBD) or IBS. This may be due to overreacting nerves in your gut, altered bacterial composition, and an altered immune response.

Fortunately, there are various methods to reduce stress on your trip. Here are some Stress-relieving suggestions for when you're traveling:

• Keep active and move your body. This might be as simple as going to a yoga class or walking for the pleasure of seeing the sites.
• Deep breathing is good for you. Deep breathing can help you relax when flying or stuck in traffic.
• Get plenty of rest. Sleeping an extra hour at night may aid the body's recovery and prevent physical and emotional weariness.
• Allow yourself more time to travel. Early arrival at the airport can help you avoid stress while waiting in line or missing your flight.

Limit Your Food Intake

During your travels, paying attention to what you eat may help you avoid the discomfort of unpleasant stomach problems. Excess eating causes your stomach to expand, putting strain on other organs and producing abdominal pain.

Eating activates your stomach to release hydrochloric acid, which aids in the breakdown of food. If you overeat, the contents of your stomach may seep into your esophagus and cause heartburn. Because saturated fats are more difficult to break down, eating fatty foods can raise your heartburn risk. As a result, your stomach develops more significant quantities of acid to digest heavy meals.

You can avoid overeating on your trip by:

• Fiber-rich foods can help you feel fuller for longer and prevent binge eating.
• To enhance digestion, drink water before, during, and after meals.
• To feel fuller after eating less food, chew your meals slowly.
• Sharing a meal to eat less-sized portions

Concerned Gut Issues While Traveling?

Stomach problems, particularly while on vacation, are never ideal. Due to the many changes in your daily routine when you travel, traveling might make you more prone to digestive issues.

GI Associates can help with screening, diagnosis, and treatment. Take control of your GI health. Contact us if you'd like to see a physician or have more questions. We treat all gastrointestinal issues and disorders with quality, comprehensive care.

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September 28, 2023

Why Do Airplane Flights Cause Digestive Problems?

The butterflies, and gas, in your tummy while you’re in flight might not just be from nerves

By Jocelyn Solis-Moreira

frontpoint/Getty Images

If you get an upset, gassy stomach while traveling on planes, you’re not alone.

The average person passes gas 12 to 25 times a day , but when you’re on a plane, you might feel like you’re constantly breaking wind. In addition to feeling gassy, some may experience an increase in other stomach issues during air travel. Though scientists have yet to directly measure digestive changes in people traveling on commercial passenger airlines, high-altitude research has revealed some clues to what’s happening in the gut when you’re in flight.

As you ascend to higher altitudes, atmospheric pressure decreases . This change in pressure makes the air feel thinner because there’s less oxygen. Low air pressure and cold temperatures at these elevations cause the air to expand, spreading out molecules such as oxygen, nitrogen and argon, all necessary components of air. When the blood doesn’t carry sufficient oxygen to tissues, it causes hypoxia, says Harvey Hamilton Allen, Jr. , a gastroenterologist at Digestive Disease Medicine of Central New York. A reduced oxygen level in the body slows down the activity of digestive enzymes , which may contribute to problems with digestion. Research on hypoxia has also indicated several other gastrointestinal (GI) changes, from an upset stomach to more severe issues, such as bleeding in the bowels, Allen says.

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Fortunately, traveling in a plane isn’t the same as climbing to the top of Mount Everest, which stands at a lofty height of 29,029 feet . Though commercial airplanes soar a bit higher at an altitude between 31,000 and 42,000 feet , they contain cabin-pressure-control systems in which conditioned air simulates a pressure akin to that at 8,000 feet of altitude.

That change in cabin pressure can still make gas in your gut expand if you have food in your stomach. Think of how your ears pop when the plane quickly ascends or descends, says Rudolph Bedford , a gastroenterologist at Providence Saint John’s Health Center in California. Like the middle ear, the gut has air-filled cavities that widen to adjust to the sudden shift in pressure.

“Changes in cabin pressure and oxygen saturation, along with the vibration and motion of the plane, can inhibit gastric emptying,” Allen says. In other words, digested food can’t move to the small intestine, making it more difficult to do a number two. This can contribute to feeling bloated, gassy and nauseated.

The length of your flight matters as well. A one-hour flight won’t disrupt your gut as much as a 14-hour trip will. Spending most of your time sitting in a cramped seat can compress the abdomen and make it harder for food to pass through. Even if you maintain a good posture, sitting for long periods of time makes it harder for the expanded gas in the GI tract to escape. “Being less active slows down your intestinal motility, thereby exacerbating bloating and constipation,” says Sri Naveen Surapaneni , a gastroenterologist at Memorial Hermann Health System in Texas. Additionally, if you have heavy foods in your stomach, this could be problematic if the plane runs into any turbulence. Surapaneni says a bumpy ride could lead to nausea and vomiting for people prone to motion sickness.

Stress might also be a culprit in a gassy airborne stomach. Research has shown that the gut has a close relationship with the brain : people with flight anxiety release the stress hormone cortisol, which reduces blood flow and oxygen to the digestive system. The decreased blood flow, in turn, slows down the digestive system. “For many people with anxiety, getting on a plane and flying for long periods stimulates symptoms of bloating, cramping in their abdomen and the butterflies-in-their-stomach feeling,” Bedford says.

If you’re someone with a preexisting GI condition, such as irritable bowel syndrome (IBS) or inflammatory bowel disease (IBD) , gastroenterologists warn that flying can worsen your symptoms. Bedford says people with Crohn’s disease , a type of IBD, may have episodes of diarrhea, while people with IBS, a noninflammatory condition that causes abdominal discomfort and altered bowel movements, report frequent bloating, diarrhea and constipation. The increase in symptoms, Bedford says, is not typically caused by the flight itself but by the anxiety of flying. Flight anxiety and underlying stress from delays or unexpected changes to travel plans may cause many people’s IBS to flare up, he says.

The good news is you can take steps to prevent tummy troubles on your next flight. Gut experts recommend drinking a lot of water. “When you’re traveling, you’re usually not drinking as much, so you’re becoming dehydrated,” Allen says. The dry air and low air pressure in long flights is dehydrating . “Dehydration due to low humidity levels in the cabin can slow down digestion and worsen constipation and preexisting IBS symptoms,” Surapaneni explains. Consider bringing a refillable water bottle with you on the plane.

If you are eating before your flight, opt for a light meal that’s gentle on the stomach. This includes lean proteins and foods rich in fiber and healthy fats, such as salmon and Greek yogurt with berries. “You don’t really want to have processed foods or salty foods before getting on a flight,” Bedford says. He also encourages people to not eat at least 30 minutes before the flight. Eating earlier can help your stomach digest the food before boarding.

Once on the plane, you’re better off skipping the wine, coffee or carbonated drinks, which might worsen an already upset stomach. Surapaneni also advises to stay mobile when it’s safe to do so, whether that’s by standing up to take a stretch or walking around the cabin.

If you have a GI condition or are nervous about an upcoming flight, it’s always a good idea to consult with your doctor before boarding in case there are other remedies they would recommend. Also, don’t fret if you continue feeling some digestive issues after landing. These symptoms are temporary and usually pass in 24 to 48 hours, Bedford says.

So the next time you’re on a plane, if you’re a little gassier than usual, Bedford says, it’s better to release it rather than attempt to hold it in for an entire flight. “Move around and let it rip—hopefully not sitting next to somebody, if you can avoid it,” he adds.

Traveler's Diarrhea: Symptoms, Treatment and Prevention

Traveler's diarrhea strikes as many as 60 percent of world travelers, making it the most common travel-related illness, according to the Centers for Disease Control and Prevention (CDC). More common, even, than its subtler cousin, traveler's constipation .

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Like other types of diarrhea, it comes with loose stools and stomach cramps and can make you feel miserable, but it usually isn't life-threatening.

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Sometimes called Montezuma's Revenge (after the last Aztec emperor in what is now Mexico), this type of upset stomach is more widespread in resource-limited regions, says Kalyani Meduri, MD , a gastroenterologist with AdventHealth Medical Group in Zephyrhills, Florida. That includes:

• Subsaharan Africa
• Central and South America
• The Middle East
• Parts of Asia outside Japan and South Korea

These are areas with warmer climates that often lack refrigeration and may have poor sanitation standards.

Here's what causes this type of diarrhea, and how to recognize, diagnose, prevent and treat it.

Causes of Traveler’s Diarrhea

Most cases of traveler's diarrhea are caused by bacteria, with Escherichia coli (E. coli) accounting for about a third of all cases, according to a StatPearls paper updated in July 2021. Other offending bacteria include Campylobacter jejuni (especially in Southeast Asia), while viruses such as norovirus, rotavirus and COVID-19 as well as parasites can also cause traveler's diarrhea.

The pathogens are typically transmitted through contaminated food and drink, says Niket Sonpal, MD , assistant professor of medicine at Touro College of Osteopathic Medicine in New York City.

Risk Factors

Traveler's diarrhea can affect anyone, but some factors make you more likely to get it:

• Being pregnant
• Being very old or very young
• Having a weakened immune system or chronic condition like diabetes
• Taking antacid or acid-blockers, as these deplete stomach acid, which would normally help kill the organisms

Symptoms of Traveler’s Diarrhea

Symptoms of traveler's diarrhea are no different from any other kind of diarrhea. They usually appear within four to 14 days of flying or any other type of travel, Dr. Meduri says, although the incubation period can be several weeks long in the case of certain parasites.

Signs of the condition include:

• Three or more loose or watery stools a day, which come on suddenly
• An urgent need to use the bathroom
• Stomach cramps
• Bloating and gas
• Loss of appetite
• Nausea and vomiting
• Muscle pain

Diarrhea associated with COVID-19 will likely bring other telltale symptoms, like shortness of breath and coughing, Dr. Sonpal says.

Luckily, most people recover from traveler's diarrhea within a week, with the worst part lasting a day or two.

A small percentage of people with traveler's diarrhea go on to develop dehydration, according to the Mayo Clinic , which can lead to sepsis and kidney failure. Signs of dehydration include dark urine, dizziness, lightheadedness, weakness and feeling thirsty.

A few people with traveler's diarrhea go on to develop a form of irritable bowel syndrome with continued diarrhea, stomach cramping and bloating, per Johns Hopkins Medicine.

Diagnosing Traveler’s Diarrhea

Most cases of traveler's diarrhea go away on their own and don't need a diagnosis.

However, doctors can diagnose the condition based on your symptoms and travel history or, in more severe cases, by testing a stool sample, according to Johns Hopkins Medicine .

How to Prevent Traveler’s Diarrhea

Regardless of the cause or symptoms, preventing traveler's stomach boils down to two key practices: Washing your hands often and being very, very diligent with what you eat and drink, Dr. Sonpal says.

• Only drink water (and ice) from a bottle or that has been boiled for three minutes or longer. The same goes for water used to brush your teeth.
• Take care not to ingest any water while you shower.
• Stick to factory-sealed beer, wine, soda or juice, and steer clear of milk and other dairy products which may be unpasteurized.
• If you're traveling to an extremely remote region, consider taking a compact water filter, advises Dr. Meduri. Iodine and chlorine tablets will also disinfect water.
• If there's no way to wash your hands, use a hand sanitizer containing at least 60 percent alcohol.
• Stick to hot, cooked food as well as fruits and vegetables that you can peel yourself. Avoid raw foods, shellfish from contaminated water and food from street vendors and buffets.
• Antibiotics aren't recommended to prevent traveler's diarrhea. The best medicines to help ward off the condition include over-the-counter loperamide (Imodium) and bismuth subsalicylate (Pepto-Bismol), as long as you take them for less than three weeks. (Bear in mind that Pepto-Bismol can turn your stool and tongue black and can interact with certain medications.)

Treating Traveler’s Diarrhea

Most cases of traveler's diarrhea are mild and go away on their own, per the Cleveland Clinic .

In the meantime, you can help calm symptoms by drinking lots of fluids, including water, electrolyte solutions and Pedialyte for children. Oral rehydration solutions can be purchased or made with half a teaspoon of salt, six small spoons of sugar and one liter of clean water.

Other natural remedies for diarrhea include: eating plain foods high in soluble fiber (think: oats, apples, citrus fruits), nixing artificial sweeteners and avoiding caffeine and alcohol.

The same anti-diarrheal drugs that may help prevent traveler's diarrhea — Imodium and Pepto-Bismol — may help treat the condition. But keep in mind that you shouldn't use these meds if you have bloody stools; in that case, you should see a doctor ASAP.

Antibiotics such as azithromycin (Zithromax), ciprofloxacin (Cipro), doxycycline (Vibramycin) and rifaximin (Xifaxan) should only be prescribed by a doctor and reserved for more severe cases.

Related Reading

5 Foods That Will Make Diarrhea Worse (and 3 That'll Help)

When to See a Doctor

Make an appointment with a doctor if:

• Your diarrhea doesn't go away after a week
• You have a high fever (103 F or higher for adults)
• You're vomiting so much that you can't keep down any food
• You have bloody stools
• You're feeling lightheaded or dizzy, or have dark urine or aren't urinating frequently (these are signs of dehydration, which can be dangerous)
• Centers for Disease Control and Prevention: “Travelers’ Diarrhea”
• Johns Hopkins Medicine: “Traveler’s Diarrhea”
• StatPearls: “Travelers Diarrhea”
• Mayo Clinic: “Traveler’s Diarrhea”
• Cleveland Clinic: “Traveler’s Diarrhea”
• Medical Clinics of North America: “Traveler’s Diarrhea”
• Merck Manual: “Traveler’s Diarrhea”
• Penn Medicine: “Travelers Diarrhea”
• Centers for Disease Control and Prevention: “Choose Safe Food and Drinks When Traveling”

Is this an emergency? If you are experiencing serious medical symptoms, please see the National Library of Medicine’s list of signs you need emergency medical attention or call 911.

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• Patient Care & Health Information
• Diseases & Conditions
• Jet lag disorder

Jet lag, also called jet lag disorder, is a temporary sleep problem that can affect anyone who quickly travels across several time zones.

Your body has its own internal clock, called circadian rhythms. They signal to your body when to stay awake and when to sleep.

Jet lag occurs because your body's internal clock is synced to your original time zone. It hasn't changed to the time zone of where you've traveled. The more time zones crossed, the more likely you are to experience jet lag.

Jet lag can cause daytime fatigue, an unwell feeling, trouble staying alert and stomach problems. Although symptoms are temporary, they can affect your comfort while on vacation or during a business trip. But you can take steps to help prevent or lessen the effects of jet lag.

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Symptoms of jet lag can vary. You may experience only one symptom or you may have many. Jet lag symptoms may include:

• Sleep problems such as not being able to fall asleep or waking up early.
• Daytime fatigue.
• Not being able to focus or function at your usual level.
• Stomach problems such as constipation or diarrhea.
• A general feeling of not being well.
• Mood changes.

Symptoms are worse the farther you travel

Jet lag symptoms usually occur within a day or two after traveling across at least two time zones. Symptoms are likely to be worse or last longer the farther you travel. This is especially true if you fly east. It usually takes about a day to recover for each time zone crossed.

When to see a doctor

Jet lag is temporary. But if you travel often and experience jet lag, you may benefit from seeing a sleep specialist.

A disruption to your circadian rhythms

Jet lag can occur anytime you cross two or more time zones. Crossing multiple time zones puts your internal clock out of sync with the time in your new locale. Your internal clock, also called circadian rhythms, regulates your sleep-wake cycle.

For example, if you leave New York on a flight at 4 p.m. on Tuesday and arrive in Paris at 7 a.m. Wednesday, your internal clock still thinks it's 1 a.m. That means you're ready for bed just as Parisians are waking up.

It takes a few days for your body to adjust. In the meantime, your sleep-wake cycle and other body functions such as hunger and bowel habits remain out of step with the rest of Paris.

The effect of sunlight

A key influence on circadian rhythms is sunlight. Light affects the regulation of melatonin, a hormone that helps cells throughout the body work together.

Cells in the tissue at the back of the eye transmit light signals to an area of the brain called the hypothalamus. When the light is low at night, the hypothalamus signals to a small organ in the brain called the pineal gland to release melatonin. During daylight hours, the opposite occurs. The pineal gland releases very little melatonin.

Because light is so crucial to your internal clock, you may be able to ease your adjustment to a new time zone by exposing yourself to daylight. However, the timing of light needs to be done properly.

Airline cabin pressure and atmosphere

Some research shows that changes in cabin pressure and high altitudes associated with air travel may contribute to some symptoms of jet lag, regardless of travel across time zones.

In addition, humidity levels are low in planes. If you don't drink enough water during your flight, you can get slightly dehydrated. Dehydration also may contribute to some symptoms of jet lag.

Risk factors

Factors that increase the likelihood you'll experience jet lag include:

• Number of time zones crossed. The more time zones you cross, the more likely you are to feel jet lag.
• Flying east. You may find it harder to fly east, when you "lose" time, than to fly west, when you "gain" time.
• Being a frequent flyer. Pilots, flight attendants and business travelers are most likely to experience jet lag.
• Being an older adult. Older adults may need more time to recover from jet lag.

Complications

Auto accidents caused by drowsy driving may be more likely in people who are jet-lagged.

A few basic steps may help prevent jet lag or reduce its effects:

• Arrive early. If you have an important meeting or other event that requires you to be in top form, try to arrive a few days early to give your body a chance to adjust.
• Get plenty of rest before your trip. Starting out sleep deprived makes jet lag worse.
• Gradually adjust your schedule before you leave. If you're traveling east, try going to bed one hour earlier each night for a few days before your trip. If you're flying west, go to bed one hour later for several nights before you fly. If possible, eat meals closer to the time you'll be eating them during your trip.

Properly time bright light exposure. Light exposure is a prime influence on your body's circadian rhythms. After traveling west, expose yourself to light in the evening to help you adjust to a later than usual time zone. After traveling east, expose yourself to morning light to adapt to an earlier time zone.

The one exception is if you've traveled across more than eight time zones. Your body might mistake early-morning light for evening dusk. It also might mistake evening light for early-morning light.

So if you've traveled more than eight time zones to the east, wear sunglasses and avoid bright light in the morning. Then allow as much sunlight as possible in the late afternoon for the first few days in your new location.

If you've traveled west by more than eight time zones, avoid sunlight a few hours before dark for the first few days to adjust to the local time.

• Stay on your new schedule. Set your watch or phone to the new time before you leave. Once you reach your destination, try not to sleep until the local nighttime, no matter how tired you are. Try to time your meals with local mealtimes too.
• Stay hydrated. Drink plenty of water before, during and after your flight to counteract the effects of dry cabin air. Dehydration can make jet lag symptoms worse. Avoid alcohol and caffeine, as these can dehydrate you and affect your sleep.
• Try to sleep on the plane if it's nighttime at your destination. Earplugs, headphones and eye masks can help block noise and light. If it's daytime where you're going, resist the urge to sleep.
• Lee Y, et al. Circadian rhythms, disease and chronotherapy. Journal of Biological Rhythms. 2021; doi:10.1177/07487304211044301.
• Janse van Rensburg DC, et al. Managing travel fatigue and jet lag in athletes: A review and consensus statement. Sports Medicine. 2021; doi:10.1007/s40279-021-01502-0.
• Kryger M, et al., eds. Shift work, shift-work disorder, jet lag and jet lag disorder. In: Principles and Practice of Sleep Medicine. 7th ed. Elsevier; 2022. https://www.clinicalkey.com. Accessed Oct. 26, 2022.
• Loscalzo J, et al., eds. Sleep disorders. In: Harrison's Principles of Internal Medicine. 21st ed. McGraw Hill; 2022. https://accessmedicine.mhmedical.com. Accessed Oct. 26, 2022.
• Kellerman RD, et al. Sleep disorders. In: Conn's Current Therapy 2022. Elsevier; 2022. https://www.clinicalkey.com. Accessed Oct. 31, 2022.
• Jet lag. Centers for Disease Control and Prevention. https://wwwnc.cdc.gov/travel/page/jet-lag. Accessed Oct. 26, 2022.
• During EH, et al. Irregular sleep-wake, non-24h sleep-wake, jet lag and shift work disorders. In: Clinical Sleep Medicine: A Comprehensive Guide for Mental Health and Other Medical Professionals. American Psychiatric Association Publishing. https://ebooks.appi.org. Accessed Oct. 28, 2023.
• Steele TA, et al. Circadian rhythm sleep-wake disorders: A contemporary review of neurobiology, treatment and dysregulation in neurodegenerative disease. Neurotherapeutics. 2021; doi:10.1007/s13311-021-01031-8.
• Moroni I, et al. Pharmacokinetics of exogenous melatonin in relation to formulation, and effects on sleep: A systematic review. Sleep Medicine Reviews. 2021; doi:10.1016/j.smrv. 2021.101431 .
• Melatonin. Facts & Comparisons eAnswers. https://fco.factsandcomparisons.com. Accessed Nov. 1, 2022.
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• Section 11 - Respiratory Infections
• Section 11 - Dermatologic Conditions

Persistent Diarrhea in Returned Travelers

Cdc yellow book 2024.

Author(s): Bradley Connor

Although most cases of travelers’ diarrhea (TD) are acute and self-limited, a certain percentage of people afflicted will develop persistent (>14 days) gastrointestinal (GI) symptoms. Details on the management of acute TD are available in Sec. 2, Ch. 6, Travelers’ Diarrhea .

Pathogenesis

The pathogenesis of persistent diarrhea in returned travelers generally falls into one of the following broad categories: ongoing infection or co-infection with a second organism not targeted by initial therapy; previously undiagnosed GI disease unmasked by the enteric infection; or a postinfectious phenomenon.

Ongoing Infection

Most cases of TD are the result of bacterial infection and are short-lived and self-limited. In addition to immunosuppression and sequential infection with diarrheal pathogens, ongoing infection with protozoan parasites can cause prolonged diarrheal symptoms.

Individual bacterial infections rarely cause persistent symptoms, but travelers infected with Clostridioides difficile or enteroaggregative or enteropathogenic Escherichia coli (see Sec. 5, Part 1, Ch. 7, Diarrheagenic Escherichia coli ) can experience ongoing diarrhea. C. difficile –associated diarrhea can occur after treatment of a bacterial pathogen with a fluoroquinolone or other antibiotic, or after malaria chemoprophylaxis. The association between C. difficile and antimicrobial treatment is especially important to consider in patients with persistent TD that seems refractory to multiple courses of empiric antibiotic therapy. The initial work-up of persistent TD should always include a C. difficile stool toxin assay. Clinicians can prescribe oral vancomycin, fidaxomicin, or, less optimally, metronidazole to treat C. difficile .

As a group, parasites are the pathogens most likely to be isolated from patients with persistent diarrhea. The probability of a traveler having a protozoal infection, relative to a bacterial one, increases with increasing duration of symptoms. Parasites might also be the cause of persistent diarrhea in patients already treated for a bacterial pathogen.

Giardia (see Sec. 5, Part 3, Ch. 12, Giardiasis ) is the most likely parasitic pathogen to cause persistent diarrhea. Suspect giardiasis particularly in patients with upper GI–predominant symptoms. Untreated, symptoms can last for months, even in immunocompetent hosts.

PCR-based diagnostics, particularly the multiplex DNA extraction PCR, are becoming the diagnostic methods of choice to identify Giardia and other protozoal pathogens, including Cryptosporidium , Cyclospora , and Entamoeba histolytica . Diagnosis also can be made by stool microscopy, antigen detection, or immunofluorescence. In the absence of diagnostics (given the high prevalence of Giardia as a cause for persistent TD), empiric therapy is a reasonable option in the clinical setting. Rare causes of persistent symptoms include the intestinal parasites Cystoisospora , Dientamoeba fragilis , and Microsporidia .

Tropical Sprue & Brainerd Diarrhea

Persistent TD also has been associated with tropical sprue and Brainerd diarrhea. Tropical sprue is associated with deficiencies of vitamins absorbed in the proximal and distal small bowel and most commonly affects long-term travelers to tropical areas, as the name implies. The incidence of tropical sprue appears to have declined dramatically over the past 2 decades. Diagnosed only rarely in travelers, its cause is unknown.

Brainerd diarrhea is a syndrome of acute onset of watery diarrhea lasting ≥4 weeks. Symptoms include 10–20 episodes of explosive, watery diarrhea per day, fecal incontinence, abdominal cramping, gas, and fatigue. Nausea, vomiting, and fever are rare. Although the cause is believed to be infectious, a culprit pathogen has yet to be identified, and antimicrobial therapy is ineffective as treatment. Investigation of an outbreak of Brainerd diarrhea among passengers on a cruise ship to the Galápagos Islands in 1992 identified that individuals with persistent diarrhea (range: 7 to >42 months) were more likely to have consumed contaminated water or eaten raw fruits or vegetables washed with contaminated water.

Underlying Gastrointestinal Disease

Celiac disease.

In some cases, persistent symptoms relate to chronic underlying GI disease or to a susceptibility unmasked by the enteric infection. Most prominent among these is celiac disease, a systemic disease manifesting primarily with small bowel changes. In genetically susceptible people, exposure to antigens found in wheat causes villous atrophy, crypt hyperplasia, and malabsorption. Serologic tests, including tissue transglutaminase antibody testing, support the diagnosis; a small bowel biopsy showing villous atrophy confirms the diagnosis. Patients can be treated with a gluten-free diet.

Colorectal Cancer

Depending on the clinical setting and age group, clinicians might need to conduct a comprehensive search for other underlying causes of chronic diarrhea. Consider colorectal cancer in the differential diagnosis of patients passing occult or gross blood rectally or in patients with new-onset iron-deficiency anemia.

Inflammatory Bowel Disease

Idiopathic inflammatory bowel disease, including Crohn’s disease, microscopic colitis, and ulcerative colitis, can occur after acute bouts of TD. One prevailing hypothesis is that in genetically susceptible people, an initiating exogenous pathogen changes the microbiota of the gut, thereby triggering inflammatory bowel disease.

Postinfectious Phenomena

In a certain percentage of patients who present with persistent GI symptoms, clinicians will not find a specific cause. After an acute diarrheal infection, patients might experience a temporary enteropathy characterized by villous atrophy, decreased absorptive surface area, and disaccharidase deficiencies, which can lead to osmotic diarrhea, particularly after consuming large amounts of fructose, lactose, sorbitol, or sucrose. Use of antimicrobial medications during the initial days of diarrhea might also lead to alterations in intestinal flora and diarrhea symptoms.

Occasionally, onset of irritable bowel syndrome (IBS) symptoms occurs after a bout of acute gastroenteritis, known as postinfectious IBS (PI-IBS). PI-IBS symptoms can occur after an episode of gastroenteritis or TD. The clinical work-up for microbial pathogens and underlying GI disease in patients with PI-IBS will be negative. Whether using antibiotics to treat acute TD increases or decreases the likelihood of PI-IBS is unknown.

Traditional methods of microbial diagnosis rely on the use of microscopy. Examine stool specimens collected over 3 or more days for ova and parasites; include acid-fast staining for Cryptosporidium , Cyclospora , and Cystoisospora . Giardia antigen testing and a C. difficile toxin assay are appropriate elements of a work-up. In addition, a D-xylose absorption test can determine whether patients are properly absorbing nutrients. If underlying gastrointestinal disease is suspected, include serologic testing for celiac disease and consider inflammatory bowel disease during initial evaluation. Subsequently, studies to visualize both the upper and lower gastrointestinal tracts, with biopsies, might be indicated.

Diagnostic tests to determine specific microbial etiologies in cases of persistent diarrhea have advanced in the past number of years. One of the most useful tools is high-throughput multiplex DNA extraction PCR. This technology uses a single stool specimen to detect multiple bacterial, parasitic, and viral enteropathogens simultaneously. Except for Cryptosporidium , these assays have high sensitivity and specificity; the clinical ramifications and the economic impact of using these diagnostic molecular panels have not been determined fully, however. In some cases, molecular testing detects colonization rather than infection, making it difficult for clinicians to interpret and apply the results properly.

Specific treatment of identified enteropathogens is usually indicated, and appropriate management of underlying gastrointestinal disease warranted (e.g., a gluten-free diet for celiac disease, medication for inflammatory bowel disease). Dietary modifications might help patients with malabsorption. Symptomatic treatment or the use of nonabsorbable antibiotics offer potential benefit if small intestinal bacterial overgrowth accompanies the symptom complex. Additionally, chronic diarrhea might cause fluid and electrolyte imbalances requiring medical management involving oral or intravenous replacement based on clinical presentation.

The following authors contributed to the previous version of this chapter: Bradley A. Connor

Bibliography

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

Connor BA. Chronic diarrhea in travelers. Curr Infect Dis Rep. 2013;15(3):203–10.

Connor BA, Rogova M, Whyte O. Use of a multiplex DNA extraction PCR in the identification of pathogens in travelers’ diarrhea. J Trav Med. 2018;25(1):tax087.

Duplessis CA, Gutierrez RL, Porter CK. Review: chronic and persistent diarrhea with a focus in the returning traveler. Trop Dis Travel Med Vaccines. 2017;3(9):1–17.

Hanevik K, Dizdar V, Langeland N, Hausken T. Development of functional gastrointestinal disorders after Giardia lamblia infection. BMC Gastroenterol. 2009;9:27.

Libman MD, Gyorkos TW, Kokoskin E, Maclean JD. Detection of pathogenic protozoa in the diagnostic laboratory: result reproducibility, specimen pooling, and competency assessment. J Clin Microbiol. 2008;76(7):2200–5.

Mintz ED, Weber JT, Guris D, Puhr N, Wells JG, Yashuk JC, et al. An outbreak of Brainerd diarrhea among travelers to the Galapagos Islands. J Infect Dis. 1998;177(4):1041–5.

Norman FF, Perez-Molina J, Perez de Ayala A, Jimenez BC, Navarro M, Lopez-Velez R. Clostridium difficile –associated diarrhea after antibiotic treatment for traveler’s diarrhea. Clin Infect Dis. 2008;46(7):1060–3.

Porter CK, Tribble DR, Aliaga PA, Halvorson HA, Riddle MS. Infectious gastroenteritis and risk of developing inflammatory bowel disease. Gastroenterology. 2008;135(3):781–6.

Spiller R, Garsed K. Postinfectious irritable bowel syndrome. Gastroenterology. 2009;136:1979–88.

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