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Balmy basecamp and the gastrointestinal fallout...literally
May 10, 2007 10: 48 EST
Although we are enjoying having higher than seasonal temperatures here, the warmer weather has its downside, too. There’s been a lot of snow and water levels are rising in basecamp. Having more than a thousand people living in close quarters means that sanitation is somewhat less than ideal. We at the clinic have seen a rise in diarrhoeal illnesses, both bacterial and parasitic. One patient was so dehydrated he required intravenous rehydration.
So lets talk diarrhea...
When a climber/trekker is suffering from diarrhea, symptoms may range from severe pain and dehydration down to the relatively minor inconvenience of having to find a toilet in a rush (unless harnessed and roped, where this becomes a major hassle!)
Knowing that there are many causes of what we call traveler's diarrhea can intimidate all of us, doctors included, when we need to diagnose and treat diarrhea. Keep in mind there is no portable test to help us diagnose the specific bug. We can make do, though, because it turns out that in many cases a diagnosis can be surmised from the history alone.
A basic rule of thumb is that bacteria and viruses that can cause diarrhea have an incubation period of a few hours up to two or three days at the most. Protozoa, such as Giardia and E histolytica, have an incubation period of seven to 14 days. Food poisoning generally occurs within two to eight hours after eating the toxin.
The history of the present illness is the crux of the matter. Understanding exactly how and when the illness began and how it progressed will generally give you a much clearer picture of the possible cause of diarrhea. We usually ask the question, "What exactly happened when your illness began?"
Bacterial diarrheas invariably have an abrupt onset. That means that the patient can generally tell you the exact time of day that they began to feel ill. Often, the illness begins in the middle of the night, or in the early morning. They are rushed from the bed by sudden cramps and the urge to defecate, and the result is a very runny or frankly liquid stool. As soon as they get back to bed, you guessed it, they have to run again. Bacterial diarrhea can be accompanied by nausea, vomiting, and fever, but the diarrhea can occur all by itself. The general concept is the abrupt onset of relatively uncomfortable diarrhea.
In contrast, the protozoal diarrheas, mainly Giardia and E histolytica, have a more gradual start of less severe symptoms. With Giardia, patients may start the day with a couple of loose bowel motions, only to feel generally okay the rest of the day. That evening they might have one or two more loose stools, but they sleep through the night, only to start the cycle the next day. After a few days, they might be more aware of a generally grumbly feeling in they intestines, increased gas, and a growing sense of fatigue. Many patients with Giardia tolerate their symptoms for two weeks or more before coming to the doctor. The general hallmark is the gradual onset of a less severe diarrhea that is generally the same day after day.
The essence of treatment advice recommended by the experts at the CIWEC clinic (see link) is the following:
1. Sudden onset of relatively uncomfortable diarrhea is probably bacterial diarrhea and and can be treated with ciprofloxacin 500mg twice a day for 1-2 days. Bacterial diarrhea and food poisoning can feel the same at first. If you are vomiting, you can't take an antibiotic in any case. If the vomiting stops and no diarrhea comes, you probably had food poisoning, and no further medication is necessary.
2. For cases with gradual onset of milder diarrhea, we assume a protozoal infection. Symptoms may include a rumbly, gassy feeling, and upper abdominal discomfort in Giardia infections. The treatment for Giardia differs around the world, depending on availability of certain drugs. Options include metronidazole, tinidazole, albendazole, and quinacrine. Metronidazole is 250mg 3 times per day for 7 days, and tinidazole is 2000mg once a day for 2 days. If diarrhea alternates every day or so with the absence of diarrhea, or constipation, with patients feeling gradually feel more tired with weight loss, E histolytica may be the culprit. The treatment for E histolytica is with either metronidazole 750mg 3 times per day for 10 days or tinidazole (2000mg per day for 3 days). Both drugs need to be followed by a course of a second drug, either diloxanide furoate (Furamide) 500 mg 3 times a day for 10 days, or paromomycin (Humatin) 500 mg 3 times per day for 10 days.
Prevention is key, and here are the main points to remember:
- WASH YOUR HANDS after using the toilet and before eating.
- Treat your water with a good filter or by bringing it to boiling or by using iodine – and don’t slip up!
- Avoid raw food. Boil first or wash and peel before eating. Remember: boil it, peel it or leave it.
- Avoid unpasteurized dairy products.
- Avoid drinking products with ice that is made from untreated water.
For more up to date information about treatment of diarrhea in Nepal, follow the link to diarrhea discussion on the CIVEC website, www.ciwec-clinic.com
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