Occasionally, I get to travel with different athletic teams, or simply go on vacation. An issue that plagues international travelers is traveler's diarrhea. The Centers for Disease Control (CDC) anticipates 20 percent to 50 percent of international travelers will develop this condition.

From a competitive athlete's standpoint, traveler's diarrhea can be detrimental if not prevented or treated correctly and expediently.

The key is to be prepared and anticipate the condition. Although traveler's diarrhea can happen anywhere, high-risk areas include Asia; Africa; the Middle East; and Central and South America. The most common culprit is enterotoxigenic escherichia coli (ETEC). Other bacteria include cholera; salmonella; amebiasis; shigella; and campylobacter. Viral infections with similar symptomology include hepatitis A, Norwalk-like virus and rotavirus. Parasite infections include helminth, giardiasis and cryptosporidium.

Usually, most cases of traveler's diarrhea are caused by ingesting foods or liquids contaminated with fecal matter. There is no gender difference as to who can contract the condition; however, young adults and older populations tend to be at greater risk.

Symptoms of traveler's diarrhea include bloating; abdominal cramping; nausea; vomiting; fever; muscle aches; malaise; and diarrhea (with or without blood). Usually, a person may average five to 10 loose stools a day. If bloody diarrhea is present, you should consult a physician immediately. Traveler's diarrhea usually lasts from three to seven days. Many cases happen within the first week of traveling, and last only one to two days. Diarrhea causes significant dehydration and weakness if the individual does not rehydrate; however, it is rarely life-threatening.

Water is a common source for bacteria, viruses and parasites, especially in Third World countries. Other potential sources include poorly sanitized glasses or cups, and ice cubes. Generally, boiled water; bottled water; mineral water; carbonated beverages; wine; and beer are safe. If none of the above are options, the water can be boiled for 10 minutes. If boiling is not an option, iodine tablets can be used. Another option is a portable water filtration system. There are many such systems on the market, some better than others. It takes time to filter the water, and can be quite expensive, but the water will be safe to drink and taste good.

Food sources to avoid are raw fruits and vegetables; salads; milk products; unpasteurized milk; shellfish; and raw meat. Raw foods can be contaminated due to poor sanitary standards. Fruits are only of concern if they are not peeled. Tropical fish such as the puffer fish and barracuda have toxins that remain active even after cooking.

Western Perspective (Medical Team Protocol)

Prevention involves paying strict attention to food and beverage choices. The Western approach to treatment includes taking Pepto-Bismol (bismuth subsalicylate, two tablets four times daily), which can decrease the incidence of traveler's diarrhea, according to the CDC. Pepto-Bismol should not be used for more than three weeks, and should be avoided by pregnant women, individuals taking anticoagulants, and individuals allergic to aspirin. The CDC does not recommend the use of antibiotics as a preventive measure.

If you acquire traveler's diarrhea, Saltines, sport drinks, juices and non-caffeinated soft drinks can be used to counteract the symptoms of nausea and dehydration. For severe dehydration, intravenous saline solution may be necessary. Antibiotics such as azithromycin and doxycycline have been prescribed by medical doctors. Another antibiotic commonly used is Cipro (ciprofloxin), which has been successful for most people, according to Dr. R.J. Williams. However, this particular antibiotic should be avoided by athletes because of its tendency to cause tendon strains and ruptures, five to seven days after ingestion.

Eastern Perspective

In addition to the above recommendations, acupuncture can be used to recover more quickly by implementing the following points in conjunction with Western medications.

According to traditional Chinese medicine (TCM), diarrhea and dysentery overlap. Organs involved include the spleen, stomach and intestines. The spleen is responsible for the transformation of the liquids and foods. The stomach is responsible for holding the pure energy. The small intestines separate clear from turbid, and the large intestines eliminate wastes. All of these processes involve energy and a rhythmic flow, provided by the liver, which disperses qi in all directions.

Damp and heat create qi and blood stagnation, affecting the collaterals and zang-fu organs. The accumulation within the middle jiao creates turbid obstruction in the intestines, affecting the ascending and descending functions of the spleen and stomach. After the initial onset, the athlete is susceptible to damp cold, based on environmental conditions. The spleen and stomach qi are deficient, enabling exogenous cold or summer dampness to invade, leading to damp cold accumulation. This is detrimental to any athlete and/or vacationer.

Traveler's diarrhea falls under the acute condition as damp heat, damp cold or food retention.

Damp Heat	Damp Cold
Hot, yellow diarrhea Foul odor Burning sensation in the anal region Abdominal pain Scanty, dark-yellow urine Thirst Yellow, greasy tongue Rapid, slippery pulse	Dilute diarrhea with undigested food Borborygmus Abdominal pain Aversion to cold Absence of thirst Pale, white-coated tongue Slow, slippery pulse

Treatments in acute cases range from once to three times daily; then every other day until the individual recovers during the attack; and once a week between attacks. The main goal is to regulate qi in the intestines and stomach.

Pattern Differentiation

Points: ST25 (tian shu), ST37 (shang ju xu).

• Dampness: (+) SP6 (san yin jiao), SP9 (yin ling quan)
• Heat: (+) LI11 (qu chi), ST44 (nei ting), GV14 (da zhui)
• Cold Damp: (+) R6 (qi hai), R12 (zhong wan)
• Food Retention: (+) R12 (zhong wan), P6 (nei guan)

Ear points: Lower jiao, Large Intestine, Spleen, shenmen, occiput, digestive subcortex, rectum and sympathetic.

• Food Retention - diarrhea, distention epigatrium and/or abdomen, decreased or loss of appetite.
• Cold Damp - diarrhea watery, abdominal pain, no thirst, feels cold.
• Damp Heat - diarrhea, burning sensation in the anal region, abdominal pain, fever, thirst.

Herbal formulas are not included in this article because, when using them for competitive athletes, the risk is too high for testing positive for banned substances.

In conclusion, traveler's diarrhea can be prevented with education and preparedness. Acupuncture can be used as a primary therapy, or in conjunction with a Western medical approach. For the athlete, the faster the individual can recover, the less energy is lost. The lost energy, dehydration and nausea make for poor performance results. Acupuncture optimizes the recovery time frame to minimize the adverse affects and poor performance. For a coach or athlete who has trained for years for a qualifying meet, Olympic trials, world championship event or the Olympic Games, contracting traveler's diarrhea can be a huge factor in the outcome. That is why it is so important to implement treatments immediately to prevent and minimize the effects.

References

1. Centers for Disease Control Web site (www.cdc.gov).
2. Williams RJ III. The effect of ciprofloxacin on tendon, paratendon, and capsular fibroblast metabolism. Am J Sports Med May/Jun 2000;28(3):364-9.
3. Mao-Liang Q. Chinese Acupuncture and Moxibustion. New York: Churchill Livingstone, 1993.
4. Ross J. Acupuncture Point Combinations. New York: Churchill Livingstone, 1995.
5. Wiseman N, Ellis A. Fundamentals of Chinese Medicine. Paradigm, Brookline, 1985.
6. Zhang E (editor-in-chief). Basic Theory of Traditional Chinese Medicine. Publishing House of Shanghai College of Traditional Chinese Medicine, 1990.
7. Chung CS, Yai KL. Principles of Dialectical Differential Diagnosis and Treatment. Traditional Chinese Medical Publisher, 1982.
8. Huang LC. Auricular treatment. Auricular Medicine International Research and Training Center, 2001.

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Click here for previous articles by Ronda Wimmer, PhD, MS, LAc, ATC, CSCS, CSMS, SPS.

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