By Trisha Pasricha
It's that time of year when patients in my gastroenterology clinic tell me about their exciting summer plans – and the dreaded scenarios that accompany them.
After a long hiatus from travel, they can imagine finally sinking their toes into the cool sand at the ocean shoreline or trekking up a picture-perfect trail to a gorgeous view.
But they can also imagine their stomach suddenly gurgling during these activities, giving them the urgent signal that it's time to go, and with no bathroom in sight.
Even the most regular person can find their bowel habits thrown off while travelling. And when nature calls at an inopportune time (or perhaps fails to call at all), it can leave holiday revellers feeling down in the… well, dumps.
"Every one of us will experience some level of altered bowel function when we travel," said gut motility expert Satish Rao, professor of medicine at the Medical College of Georgia at Augusta University.
"It's extremely common, even though no one likes talking about it." He emphasised that travellers should take proactive steps to stay regular, rather than waiting until something uncomfortable happens.
Here's why those unpleasant changes in our guts happen and how you can keep them from ruining your next holiday.
Traveller's diarrhoea
During the height of the pandemic, concerns about classic traveller's diarrhoea faded into the background, because few people were travelling anywhere.
Now that we're travelling again, you should be aware that 11.5% of patients with Covid-19 experience diarrhoea, according to a 2020 systematic review of 43 studies, and a different 2020 systematic review found that up to 1 in 6 of such patients have only GI symptoms. So, it's always worth having rapid antigen tests handy on holiday.
But traveller's diarrhoea also should be on our radar, advised Ronald Blanton, chair of the Department of Tropical Medicine at Tulane University's School of Public Health and Tropical Medicine.
Up to half of travellers from high-resource regions of the world develop diarrhoea, which is usually caused by a bacteria such as E. coli, according to a 2017 study published by researchers from Helsinki.
Today, few doctors would recommend taking antibiotics to prevent diarrhoea when travelling because of the medications' side effects, the fact that most cases resolve on their own (usually within five days) and widespread antibiotic resistance caused by overuse.
Regina LaRocque, an infectious-diseases specialist at Massachusetts General Hospital, studied bacteria in the stool of 608 US travellers who returned from trips abroad. She found that people who had taken antibiotics for traveller's diarrhoea were more likely to have drug-resistant bacterial strains in their guts that remained there even months after their trips.
Instead of antibiotics, Blanton counsels people who want to be proactive to try taking daily Pepto-Bismol, which contains bismuth subsalicylate and can be up to 65% effective in preventing traveller's diarrhoea.
Generally speaking, well-cooked foods are less likely to transmit pathogens. (If you do consume raw foods, choosing items with a peel that you take off yourself, such as bananas and oranges, is safer.)
Blanton also encourages travellers to adjust the times they dine according to local customs. "If you go to have dinner at 6 o'clock in Mexico City, that food has probably been there since noon, because people eat (dinner) much later than that," he explained. "So food is prepared freshly much later."
As for drinks, although steaming-hot coffee and tea are generally okay, you should use only bottled water that you open yourself – even for brushing your teeth, depending on your location.
"It is important to feel or see that the seal on the bottle is broken in your presence," Blanton said. If not, there may be a chance that the bottle has been filled from the tap or other sources.
But even if you follow all the rules, you could get sick. If you do end up with traveller's diarrhoea, staying aggressive about hydration is critical. It's usually safe to take a medicine such as Imodium to slow down the frequency of stools, especially if you're in a constrained situation such as about to board a flight, but anti-diarrheals should be avoided if your stools are bloody or if you have a high fever.
In that case, you should immediately seek help locally. Other concerning symptoms include being dehydrated, dizzy or unable to keep any food down.
Another reason to seek out a physician is if your symptoms persist for more than two weeks, whether at home or abroad. That could be a sign of an atypical infection (such as from a parasite), depending on your activities while travelling.
Or, as I frequently see in my clinic, it could be the result of irritable bowel syndrome – a long-term disruption to bowel habits sometimes triggered by an infection – which happens to almost a third of patients after experiencing infectious diarrhoea.
Traveller's constipation
Although less well-publicised, developing constipation while travelling is about as common as developing diarrhoea (a 2003 study estimated that it affected about 40% of international travellers) and no less frustrating. Unlike with an infectious etiology, traveller's constipation tends to arise from disruptions to your gut's normal routine.
"Constipation is well-known to happen among night-shift workers, people like airline hosts and hostesses, or nurses whose schedules are constantly varying," said Rao, who studies the way daily activities affect how the gut moves.
In the 1990s and 2000s, he conducted experiments in healthy volunteers examining how the colon responded to eating, sleeping, exercising, and physical and psychological stress.
He and his team found that, at night, the colon "sleeps" in a more quiescent state, but as soon as we wake up, it begins to buzz with a threefold-higher rate of activity that lasts about an hour and a half. That's why many people find it easiest to have a bowel movement first thing in the morning.
"Your colon has an intrinsic rhythm and clock," Rao said. "When you travel, you can't expect your colon to function normally, because that clock becomes completely shattered."
Plus, it's often difficult to exercise on holiday.
"Even if you're relatively active, if you're sitting on a plane for hours, you become almost completely immobile," he said. "That's not helping your colon."
Stress, a common feature of many a family holiday, can have a big effect on how we poop.
Although psychological stress can stimulate bowel movements (if you've ever suddenly had to use the restroom right before your turn at karaoke, you know), most people need a "safe," clean and preferably private commode to feel comfortable pooping, Rao said. That can be difficult to find while travelling, which can lead to constipation.
Some factors, however, are more within travellers' control. If your holiday involves indulging in low-fibre foods, which can aggravate constipation, try consuming more fruits and vegetables or taking a daily fibre supplement to keep things moving. To combat dehydration, which can dry out stools, I recommend that my patients drink plenty of fluids.
Last, because drinking caffeinated coffee also increases contractions in the colon, incorporating this into your morning ritual might give you the boost you need.
"I advise all my patients: Try to stick to your routine as much as possible," Rao said. "Take a little extra medicine with you if you already have constipation at baseline to try and cope with this."
The bottom line (no pun intended)
Travelling now, as it always has been, is about weighing risks and benefits. Indulging in local cuisine and escaping your usual habits are great parts of a holiday.
Knowing that your bowel habits will probably change during your trip, taking proactive steps to stay regular and having a plan in place if things deteriorate can keep the focus on relaxing and, hopefully, minimise the time you spend in the bathroom.