The first fundamental principle to consider is that one acute bout of dysentery enhances resistance to another. From this it follows that victims of acute dysentery should drink without worry; the primary concern is dehydration. Some of the reasons follow from simple observations of how a body responds to the perception of a biological toxin or foreign organism.

Mechanical: The pyloric sphincter that regulates the movement of substances between the stomach and the small intestine contracts. In fact, it goes into a sustained spasm. The contents above the sphincter are regurgitated, and anything in the lumen of the bowel below the sphincter is purged. A lot of fluid is secreted into the bowel to help wash things out. The net result is that any foreign proteins or organisms tend to get flushed out of the tube. Several other biological reflexes come on line that are also well modeled as partially mechanical in nature, even though they are chemically mediated. The net result is that they limit the ability of foreign organisms to invade the lining of the GI tract.

Immunological: Once a threat is perceived by one part of the system, the entire system tends to activate. Chemical messengers are secreted into the local area as well as the whole circulatory system. These chemical messengers tend to activate all of the immune cells in the body, as well as the local area. Most immune cells can be modeled as sleepy and lazy under ordinary circumstances, but they tend to become ferocious in response to chemical alarms sent out by other cells. Once activated by a messenger from another cell, these cells send out more alarm messengers, which amplifies the response. An invading organism has its best chance of getting past your immune defenses while these cells are quiescent; it’s a lot harder for the same bug, or any new bug, to get through once the system is activated.

The net result of all of these defenses is dehydration: you vomit fluids, you secrete fluids into the gut that are evacuated as diarrhea, and your circulation increases in speed as well as volume per unit of tissue. The best treatment is to drink as much fluid as you can tolerate. Some of the pure water you drink will be absorbed across the gastric mucosa, but none of the particles in the water will be. Some water and some of the smallest particles will get past the pyloric sphincter, but the bowel will only absorb the free water. It will purge most of the water and any particles in it. While I don’t have hard data in hand from a prospective clinical trial to prove it, it follows that an acute bout of dysentery will tend to make its victim more resistant, not less resistant, to attack by another biological toxin or organism in the fluid you drink to treat the acute dehydration.

It’s not clear that there are any circumstances where this principle wouldn’t hold true for the treatment of acute dysentery in otherwise healthy adults. Of course, people with certain types of special disabilities or chronic illnesses might be forced to contemplate more complex scenarios, but it’s probably better for most people to drink water that is of uncertain purity than to risk the consequences of dehydration. Again, dehydration can kill, and kill quickly, while most of the causes of acute dysentery are much more limited in their ability to cause morbidity and mortality.

Again, as we’ve all acknowledged, some discretion and an appreciation of the local environment is indicated. One wouldn’t be well advised to drink turpentine, tequila, or tea that had been made by the KGB. But, my old professors still seem correct: drink as much as you can even if you are certain to vomit part of every mouthful.

Incidentally, psyillium is very benign, even in neonates and toddlers. It’s only contraindicated in astronauts and people who have undergone certain types of bowel resections.

Very best.

Mozley

Also I was asked about the link for “Unwelcome guests Pt.1″ that can be found here:

http://www.polosbastards.com/artman/publish/article_139.shtml

Best,
Stiv

My main question/comment concerning biological contamination is grounded in the situational consideration. Suppose a traveler was hit with the symptomatic diarrhea while in the hinterlands (trekking, out-of-the-way sight-seeing, etc). Perhaps a trip to a place with proper treatment is at least 3-4 days out (either because of distance or because local transport only runs as such). Let’s also assume that water must be rationed, or perhaps its nearest source cannot be trusted (in effect creating a rationing situation of available, trusted water). My question seeks to understand the optimal choice: risking a second biological contamination by using possibly contaminated water (out in the wild, so to speak) or ingesting only that water which can be insured safe? It seems there are many factors that could affect the balance here, and I would venture to guess that your advice would still be to drink what water is available and relatively safe – I guess my question boils down to this: at what time, in what situation, is it a good idea to ration or hold off? Is Cholera the most biologically significant risk (if lag times over 5 days or so were considered “safe”)? This is not really meant to be a negation of anything that was said, but just my brain firing off possibly problematic scenarios.

>In summary, fluid is the first line of treatment in cases of acute traveler’s dysentery. It is prudent to >secure a source of safe water wherever you go. Put a liter of a fluid you trust near your bed every >night. It’s not likely to go to waste even if you remain perfectly healthy.

This is great advice. I commented to Steve, this page (especially with your response here) has provided me extremely useful information on the subject. I was an EMT a while ago (for a few months in college) but unfortunately most of its specialized knowledge does not translate well to travel and life in developing countries. We discussed dysentery but only as much as it affected the young and the old, and of course the small scope of interventions in which an EMT-B is allowed to practice with regards to the illness (we can’t even start an IV). I never came across a case of it in my short time working (and thank god have not been afflicted with it yet while traveling).
Always a pleasure to see learning combined with a willingness to spill the beans on topics of expertise. Appreciate it much.

Fansy

Drinking biologically contaminated water. It’s fair for you to note that most people don’t prefer to suffer from a major illness caused by the treatment of a minor illness. The probability of contracting cholera from water along stretches of the Congo is almost 100%, and it’s often fatal. (Until Dr. John Snow discovered the association between sewage and cholera in 1855, the same could once be said for stretches of the Thames.) Cholera is an interesting case in favor of your point because its latency is short. That is, the time lag between drinking infested water and getting sick is often only 1-to-3 days. Most other infectious agents in water have 7-to-14 day lag times, and the amebiasis that I once contracted in Irian Jaya had a latency of almost a month. Perhaps it means that in extreme scenarios, such as those in the middle of the night in places where one is forced to drink tap-water from unreliable sources because there are no reasonable alternatives available, there is often enough time to start prophylactic antibiotics after the acute dysentery has passed. This principle probably holds for most bacterial and parasitic infections in otherwise healthy adults who will not die from ingesting common GI viruses like little children often do.

Drinking chemically contaminated water. Similar considerations hold, although the lag-times for most diseases caused by chemicals in drinking water are quite long, many being measured in years or decades. Chemically induced diseases usually require chronic exposure to relatively high doses of the chemotoxin, and as a consequence, very large volumes of contaminated water. In other words, the relationships between dose and risk seem much more straightforward for chemicals than biologicals. In many cases, where it’s only the chemical quality of the tap water that is uncertain, it’s probably best to drink it liberally during a bout of acute dysentery. But, as you and others alluded to, sensitivity to the local environment and a modicum of discretion seem indicated. After all, it apparently required only one cup of polonium-210 contaminated tea to kill a man in London last year.

Drinking water with minerals. Most bottled waters are relatively expensive for good reasons related to their safety. Caution, however, is indicated in this context when it comes to the concentration of magnesium (Mg++). Magnesium is an effective laxative. Its concentration in most bottled waters is too low to cause a problem, but I once saw it induce a diarrheal syndrome resembling dysentery in two American women in Morocco who constantly drank locally bottled mineral water as a matter of nervous habit. If there is doubt about the integrity of bottled water, one can select “water with gas”—that is, carbonated water. The extra bicarbonate is actually good for your health when you’re vomiting a lot, but the key point here is that tap water or river water cannot be fraudulently sold in a used bottle as “water with gas”.

Remember, dehydration kills, and kills quickly. It’s ultimately the cause of death in old men who have heart attacks while shoveling snow, as well as young sailors who fall into the North Atlantic for much more than about 20 minutes, even if they’re pulled out alive. It took only one day’s march to dehydrate the Crusader’s army from Jerusalem in 1187. Saladin (Salah al-Din) then massacred them while they struggled to reach the water’s edge in a weakened state.

In summary, fluid is the first line of treatment in cases of acute traveler’s dysentery. It is prudent to secure a source of safe water wherever you go. Put a liter of a fluid you trust near your bed every night. It’s not likely to go to waste even if you remain perfectly healthy. It’s not always wise to try sailing across a sea or trekking across a desert without secure provisions for water.

Incidentally, the relationships between hydration and performance are beyond the scope of this conversation. I will say only that if you’re a racehorse trying to win the Kentucky Derby in a 120 second burst of speed, dehydration could be advantageous. That’s why it’s illegal to give racehorses furosemide (Lasix). But, travelers who are out on the road for a long time seem well advised to act more like turtles, and keep themselves hydrated.

As his advice is very water intensive, the small benefit you get from ingesting water whilst puking will be negatively offset, I believe, by the lack of good water to drink following the episode – at which time you really can hold it down and are at your most dehydrated state.

I’ll try and scare up Moz for some more input.

Best,
Stiv

I wonder, if a situation called on the rationing of water, what would be the optimal solution. As much as possible at first? Saving it until after the acute episode? I remember my father always used to tell me, taking on the tone of veteran a Native American brave, that the silly white man would ration out his water while crossing the desert instead of drinking as much as possible up front. My father is not Native American and so I always doubted this piece of advice, but it seems pertinent to the topic; and in turn I diarrheaed it right out of the dark recesses of my brain for all readers to enjoy and marvel at.

http://www.ratemypoo.com