Unwelcome guests Pt.2

steve.jpgAfter reading my PBlog “Unwelcome guests” my dear friend Dr. Dave Mozley made some insightful points to me about some other aspects in the treatment of travelers diarrhea that he thought would be helpful to others in the context of traveling to developing countries. Dave and I have made many difficult trips together and he’s taught me a great deal about a variety of topics and the handling of all manner of trying situations while abroad. Dave has been traveling all over the world for years and he’s been a member of the medical community for over twenty years. He’s currently working in research for a major pharmaceutical company in the United States.

I think you’ll find the real beauty of “Moz’s” approach to travelers diarrhea is it not only lays out the physiologic mechanisms of the affliction but also gives some very pragmatic and logical solutions for curing this all too common woe abroad, and some really viable treatment options so you won’t be “Shit out of luck” if you didn’t pack Immodium or can’t get your hands on any Cipro, or worst of all contract one of the new anti biotic resistant strains of bacteria that are becoming more and more common throughout the world.

By Dr. Dave Mozley M.D.>

Palliative Treatments of Dysentery

Purpose: As Napoleon observed, diarrhea has defeated more armies than all of history’s great generals combined. The specific aim of this prescription is to review some of the steps that stricken travelers should take to get back into combat as quickly as possible.

Background: Most travelers’ diarrhea syndromes are caused by pre-formed endotoxins. The “loudest” of these proteins tend to be resistant to degradation by stomach acid, bile salts, and the alkaline environment in the small bowel. No medication will destroy them. They must be eliminated. Once they bind receptors in the gut, they produce secretory diarrheas. Simply put, the gut tries to defend itself from invasion by what it assumes are live organisms by flushing them out with water. This is the key point from which all rational treatments follow logically.

Methods: the treatment of vomiting. The water for the gut’s fire hydrant comes from the extra-cellular fluid. Water in the extra-cellular fluid comes from the blood. Water in the blood comes from direct absorption across the gastric mucosa (and the distal colon). So point one is to put as much fluid as possible into the stomach. It does not matter how much you are vomiting. It’s virtually impossible to throw up more water than you put down. If you don’t get lots of water in, then the water going out will leave you dehydrated. Dehydration is pathological for a variety of reasons, not the least of which include the shunting of water from the muscles other internal organs to the gut, leaving you weak. Your brain suffers, and in its attempt to cope with the situation, tries to put you down on your back. Water is good medicine and exactly what you need for a variety of reasons. It’s relatively easy to regurgitate. Barfing up undiluted gastric juice is harsh on your esophagus, and bad for your teeth. Adding a lot of water to your stomach is a good way to wash out any remaining food as well as the offending agents in them. You should engorge yourself with water until you are regurgitating only clear, non-bitter tasting fluid. Some physicians like to prescribe clear sodas, like 7 Up. They taste good, and the bicarbonates in them are great buffers for gastric acids. The sugar in them can mitigate the feelings of lassitude. Colas are not favored because of their caffeine content. Caffeine tends to sustain and prolong the signal transduction caused by the binding of the endotoxins, so it can be thought of as relatively contraindicated. Dentists, of course, are appalled by the prescription of any sweet soda waters. Tooth decay is greatly promoted by stomach acid, and they would argue that any kind of sugar water in the oropharynx adds insult to injury. Apple juice is a reasonable compromise that is endorsed by many pediatricians. Orange juice is contraindicated because it is very acidic. Teas are worse because the solute loads in them cause the kidneys to loose more water excreting the solutes than the amount of fluids in the brews that are absorbed by the gut. Complex solutions like Gatorade or the electrolyte packets you add to water are unquestionably beneficial for the subchronic stages of major dysenteries, but free water is all that’s indicated during the acute stages of almost any diarrhea, and all that most travelers ever need. And, it’s often all that’s available when these syndromes wake you up either 6 or 12 hours after ingesting the problem.

Methods: treating diarrhea. Back in 1983, the family practitioners in rural North Carolina taught me that the psyllium they usually prescribed for constipation was the treatment of choice for these kinds of diarrheas. Their rational was so clear and compelling that the white haired physicians in Center City Philadelphia didn’t take more than a minute to convince that this was also useful on the urban wards when I interned in 1984. Products like Metamucil and its competitors work because they cannot be digested or absorbed by the gut. They are hydroscopic, meaning they absorb water. But, they hold the water they absorb within the lumen of the gut, where it forms a slurry, that is, a sort of mud. That’s nice for people who suffer from the constipation caused by hard, compact, water deficient feces. The same phenomenology applies to diarrhea. The psyilium mixes with the secreted water and forms a mud. Even nicer, whatever is dissolved in the water moves into the mud with it. Most endotoxins are water soluble proteins that are easily trapped within the mud. Live bugs are stupid, and get trapped in there too. As a consequence, the endotoxins are not able to bind the receptors on the brush border of the gastrointestinal (GI) tract. In this way, the offending agents are removed from the compartment that causes harm before they are eliminated from the intra-luminal space. When they are eventually eliminated from the terminal end of the GI tract, evacuating a slurry is gentler on the rectum than passing water. It’s also less messy, which might explain why some of the Philadelphia nurses were as enthusiastic as this kind of treatment as some of the physicians and patients. (And that might be an important point; anecdotal as it might be, patients almost invariably agree these maneuvers are helpful.)

Methods: re-feeding. The time to start eating again is before you feel like it. Practically speaking, with either a 6 or 12 hour lag time between ingestion of the offending agents and the start of their repudiation, most bouts of dysentery start during the night. As a consequence, you should plan on eating breakfast. Pediatricians usually recommend a BRAT diet: bananas, rice, applesauce, and toast. A multivitamin (with lots of water) is generally all that’s necessary to replace depleted electrolytes, such as the potassium that’s lost with vomiting. Gatorade and packets of electrolytes are nice if available, but unnecessary. Whatever you eat, select foods that are relatively easy to digest (and regurgitate in case you’re not quite done). Cereals are perfect. Avoid most fruits; they taste good, but are generally hard to digest. Nuts are difficult to digest under ordinary circumstances, and not recommended except as an unavoidable component of granola bars and trail mixes. A lot of thoughtful people recommend local yogurt for a variety of reasons. Whether or not the big bacillus in yogurt can really reach the colon and help establish a new and improved equilibrium is not really clear, but it tastes good and is easy to digest.

Drugs: Medications are available to terminate any and all of the symptoms of dysentery. But, none are recommended for travelers’ diarrhea, and most are contra-indicated. Food gets trapped in the stomach due to a healthy reflex that sends the pyloric sphincter at the gastroduedenal junction into spasm. You want to eliminate this food, and since there’s only one way out, puking is a physiological, i.e., healthy, response to the insult. Similarly, you want the offending agents that already made it into the small intestine out of there, and since the only way to get them out is through the back door, you want to avoid the anti-diarrheals. Save these for 12 hours after the last episode of vomiting if you need to be on the move. Otherwise, a second dose of Metamucil will serve you better.

Summary: Plan on coming down with a case or two of dysentery. Carry individual packets of psyllium fiber (about 0.4 oz or 12 grams per packet). Push fluids hard once stricken whether you feel like it or not, and keep hydrating yourself as much as possible between episodes of vomiting. Avoid medications for symptomatic relief until you’re sure the acute episode has passed. Carry multi-vitamins, as they’re always good for you and extremely beneficial in situations like these. Anti-bacterials like Cipro are not the first line of treatment for classic episodes that start 6-to12 hours after ingesting nasties. In most cases, you should wait at least 12 to 18 hours to see if hostilities end on their own before starting a chemical war.

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