Is Your Diarrhea Traveler’s Bug (Montezuma’s Revenge) or Something Way Worse?

Hey, I’m Doctor J. Welcome to the Esprē Health podcast.

Today we’re going to discuss something that is kind of, I don’t know, outside of the box a little bit. It’s a term that’s used in medicine, and pretty commonly it’s called Montezuma’s revenge. You’ve probably heard of it, right?

And that phrase usually means traveler’s diarrhea. It’s unpleasant. It’s inconvenient. It can ruin your vacation.

But what if it’s not Montezuma’s revenge that you have? What if it’s this new thing called cyclosporiasis? I mean, how would you know the difference?

That pretty much changes the plot because it’s not, you’re sick for a day or two and then it’s over. I mean, this could take a while.

You might not have traveled. You might have had a salad that traveled. I mean, it might have come up from South America or Mexico. It doesn’t really have a clear picture of where it came from. They’re saying it’s a prepared thing from somewhere like Chipotle or Taco Bell or somewhere like that, but none of that’s been really clearly proven.

But instead of like a 24-hour pain in the… you have a week or more of explosive, watery diarrhea. Doesn’t that sound awesome? Yeah.

And fatigue and bloating, and you realize that your gut’s doing a hostile takeover and it’s not your friend anymore.

And the question is: Is this traveler’s diarrhea, or is it this really funky parasite? And do I need different diagnosis and treatment?

Well, here’s the thing that I want you to walk away from: You need to learn to listen to your body.

I tell people about this all the time. We have a technique that we use called looking at your poop. And basically what you have to do is, when you have a bowel movement, you look and see what you’ve left behind.

It sounds a little gross, but it’s not that big a deal, right?

But if you look at what you’re actually producing in your body, it’s kind of like you go to the mechanic and he checks out the exhaust in your car to find out if it’s running right. So you do the same thing. You just check it out.

And if it looks funny, there’s something wrong, right?

If you have a normal understanding of what your poop looks like, it should look like that. If it changes for a bowel movement or two, it’s not a big deal. But if it changes consistently for a long time, it becomes really soft, or it changes to yellow, or it changes to another color like green, as a doctor, I know these different colors mean specific things.

Yellow is probably your liver. Green’s probably Clostridium. Bad stuff, right?

What I’m asking you to do, though, is become an expert on what your body is telling you.

We built a system called Esprē. Esprē technology basically is an online questionnaire that you fill out, and it studies all the different possibilities that your body is producing for you, your symptoms. It tells you all the symptoms and how they connect to give you an idea of what’s going on inside your body.

So what is really Montezuma’s revenge?

Well, that’s a casual label that people use because it’s kind of funny, you know? Montezuma had a big problem with the Mexico invasion, and the way he gets back is everybody gets this terrible bug, right?

But that’s not what the bug is.

The bug is a thing called pathogenic or diarrheagenic E. coli. Everybody’s got E. coli. It’s the E. coli that’s your friend. It makes your gut work really good.

But there’s this bad one. It’s from the south. It doesn’t speak your language immunologically. It creates problems, right?

There’s a whole lot of things that cause problems like that. Viruses do it. Parasites do it. Norovirus and all these other things that are a big deal.

But this thing, the Montezuma’s revenge, is real straightforward.

You’re traveling, right? You go and you drink some water, or you drink some kind of drink or whatever that was mixed with water, or you have vegetables that were washed with the water. Typically, it’s waterborne.

So the water from South America and Mexican countries that are not really clean, they’re going to cause this, right?

It’s abrupt. It’s uncomfortable. It’s really a mess, right? Usually it gets better.

What I do with my patients, and this is the other thing great about the whole Esprē idea, is we have patients who we have relationships with. So when they go on a trip, I am not jealous. I’m supportive. I want them to have a great trip.

So I provide them with antibiotics. I tell them, before you go, let me make sure you have a prescription. I give them erythromycin. I give them Zofran. I give them instructions to take Imodium if they need it, but only when they take the antibiotic, right?

That way they’re prepared.

The other thing that’s cool is if they wind up with an upper respiratory infection, Zithromax is perfect. It almost works every time for it. It’ll definitely reduce the length of time you have it, but it’s a great thing to have, and that’s really important when you go on a trip.

Montezuma’s revenge is not something to be feared. It’s something to be aware that that might happen.

Don’t ever take something to stop your bowels from moving if you’re not going to take an antibiotic first. That’s dangerous. You create problems, right?

But if you have the antibiotic, then you can use something to slow your bowels down so you’re just not miserable, right?

Montezuma’s revenge is the umbrella term.

Cyclosporiasis is something quite different. It’s the storm that just kind of takes you. And the real name for it is Cyclospora cayetanensis.

Pretty cool, huh? Went to medical school so I could do that.

It’s a parasite, and it’s also frequently through water. Sometimes it’s food, but usually fresh produce, right?

So instead of this rapid-onset problem like Montezuma’s revenge or food poisoning, Salmonella, Shigella, all those other guys, these symptoms, they’re like maybe five to seven days, a week or so, after you’re exposed.

So God knows where you got it from, right? I mean, I can’t remember yesterday, let alone, like, what did I have? A salad last Tuesday? I don’t remember.

But what you know is that you get this crazy, watery diarrhea. And usually what happens is you have it many, many times and then it’ll stop. You’re like, “Hey, it’s over.”

And then it comes back, right?

And you’re bloated, and you have gas, and all of that stuff happens with cramping. And you’re not very hungry, and you’re fatigued. Sometimes you’ll have some weight loss and dehydration, which is a really big deal. That’s when people get in trouble.

So you need to know, if you start to get really, really fatigued and you begin to have problems with keeping enough water in, then you need to do something about that, right?

With Cyclospora, you don’t get a lot of vomiting. So that’s atypical. For revenge, puke. With the other ones, Shigella, Salmonella, those you’ll puke.

So what you want to remember with the differentiation between the two: You’re listening to your body. You’re paying attention.

Who knows when you ate what?

But you do know that Montezuma’s revenge is a sprint. Cyclospora is a marathon, right?

And you’re not going to get a medal, just so you know. It’s not going to happen.

So persistent diarrhea, you shouldn’t just say, “Well, it’ll just get better.” If it lasts more than a day or two, especially if you’re super uncomfortable, especially if you can’t keep fluid down, right?

I do a bunch of stuff in my integrative medicine practice. I do stool analysis. The thing about that is you have to do a special test for Cyclospora. It’s a very specific parasite test with a specific stain and all that stuff.

But if you’re listening to your body, or if I’m listening to your story as your doctor and I really pay attention, we can pretty much make the call, right?

The treatment of Montezuma’s revenge and the treatment of Cyclospora are completely different. It’s a completely different antibiotic.

But one thing that’s a classic, you do it for everybody all the time when they’re having vomiting and diarrhea, is that you rehydrate them the best you can, right?

If they’re not holding stuff down orally, at some point they need to get IV fluids. But most people, you can wiggle around that.

Zofran is a medicine, ondansetron. You stick it under your tongue. It comes in four- and eight-milligram strengths. Every six to eight hours, you can take one. For most people, it stops vomiting.

You can also get a shot of other medicines, Phenergan, stuff like that.

Anyway, oral rehydration fluids are really important when losses of fluid are a big deal. You replace fluid, just the water and electrolytes.

And you can tell if you’re really getting in trouble if you stop peeing.

We’re going to talk about poop and pee. Right on.

And you get even more than that, you get dizzy or confused, and it gets worse and worse and worse. At that point, you have to see a doctor. You have to go to an ER, clinic, urgent care, or something. Get that taken care of.

The way that you make rehydration solution is not that you go to a store and buy a sugary, colorful drink.

You know, all those sports drinks that are supposed to be rehydration solutions. People do it all the time, and it’s better than nothing, but just barely, because you’re adding a whole lot of stuff you don’t need and you’re not getting enough of the things that you do.

So what you really need is water, of course, and you need salt. And your body can tolerate a lot of salt, a lot more than you think.

If you’re a very purist and you’re a medical person, you want it in liters and grams. You want 2.5 grams of salt and you want a liter of fluid, right?

Okay. Or half a teaspoon and a quart. That’s because I’m an equal-opportunity measurement guy, and you need to know it’s easy.

So half a teaspoon of salt with a quart of water.

And then if you have a little bit of magnesium and potassium, you can add that to it. If you don’t have it, it’s okay. It’s the salt that you really need unless it gets really, really protracted.

So for really mild diarrhea, just a little bit of fluid.

And I’ll tell you what else is really a big deal. People who get these kinds of problems temporarily may get lactose intolerant. So adding dairy at that time is a bad idea. Just limit the dairy, right?

It’s just like a little pro tip. Just limit dairy at that time because no matter what you have, if it’s food poisoning with Shigella, Salmonella, Montezuma’s revenge, if it’s Cyclospora, whatever, all of that is more likely.

So things that you can get over the counter that really help. It’s super old-fashioned. I don’t know if you remember commercials from Pepto-Bismol from a million years ago.

It’s that pink stuff that coats your stomach, and they have little, you know, graphic images of that.

But it’s really interesting because it has a compound called bismuth in it, and bismuth has a lot of anti-infective activity.

Plus, it looks really cool. I mean, it’s a really cool color. And if you had a car painted that color, it would be really cool.

So bismuth compounds can be chewed. They have chewables. It makes it really easy so little kids can use them. And you can be pretty liberal with them. It’s hard to get in trouble with them.

One thing it will do, though, if you’re looking at your poop, is it can turn your poop black. Do not be alarmed. That’s your Pepto-Bismol doing that.

The other thing you get over the counter is Imodium. It’s called loperamide. That’s the other name for it.

And Imodium slows your bowels down. It doesn’t stop your bowel. It’s not the permanent cork. It doesn’t just totally end things.

There are stronger drugs that do. A doctor has to prescribe them. They’re even considered narcotics.

But they’re really good to have on hand. And don’t use Imodium unless you have an antibiotic on board.

So if it’s interfering with your activity, then definitely antibiotic and loperamide, the Imodium. But definitely have a doctor involved at that point, right?

For severe diarrhea, dysentery, fever, that’s like blood in your stool and stuff like that, big time, get evaluated.

People will do stuff when they’re on vacation that’s pretty risky. They’ll decide, “You know, I feel really bad, and I’m starting to hallucinate, and I haven’t peed in a day, and I just want to get on the plane and get home.”

It’s probably a bad idea, right?

Because planes are an environment where your body is stressed even further. Better to get treated before you leave.

Most countries with travelers, if it’s even barely sophisticated, they’ll know how to rehydrate you. So don’t be afraid to get yourself rehydrated if you’re getting in trouble.

So if there’s blood, fever, severe pain, or you can’t stay hydrated, don’t push through it, right? Just get taken care of.

If you have cyclosporiasis and you’re pretty sure, like it’s been a week, a couple of people you know have it, you’re having this explosive diarrhea, all that stuff, only a doctor can take care of that antibiotic and the way that you “antibiotics.” I think that’s a word I just made up.

Anyway, if you use antibiotics, you have to use something called trimethoprim-sulfamethoxazole, or Bactrim.

The thing about that is you want to make sure that you really need it because it has some profound side effects in very rare cases, but it happens. So I like to use those drugs really carefully.

And be sure, if you want to wait for a stool analysis to come back, that can take a long time. So better get the history, know what you’re talking about, and figure it out.

And then you give this Bactrim for about a week.

You just need to make sure the person is not allergic to it and they’re not pregnant. And, you know, use good judgment because IV fluids and anti-nausea drugs, that will get you through it.

And we’ve taken care of a lot of people like that. It works great.

So for you, you need to know: half a teaspoon of salt in a liter of water, antibiotics when they’re indicated, and then Imodium, right?

So the most important thing, though, is that you know what your body is telling you, right?

A little bit of diarrhea like that happens to people with food. Sometimes you’ll get like a real trace food poisoning, eat something on an airline or something, and you just get a little upset stomach. That’s not a big deal.

But when you’re dealing with something like Cyclospora, it can be a really big deal. If you’re already a sick person, it can be a really big deal. Most healthy people don’t need to worry about it.

When you think about an explosive diarrhea outbreak, man, that is just like media overhyping. And I think people are fairly accustomed to media overhyping from all the stuff that happened with COVID and everything else.

And the Cyclospora problem is definitely a problem, but I think it’s way, way overdone.

And the fact that you would avoid vegetables. I have a family member who I love very much who, for a couple of weeks, wouldn’t eat anything green. No vegetables.

I think, come on.

And there was no amount of washing or whatever that would convince her that that would be okay. But now she’s over it and she’s back to broccoli, so that’s good.

This is not routine traveler’s diarrhea, but it’s not the end of the world, and it’s not really a big deal.

In fact, by today, I think the cases are dropping dramatically and everything’s better.

And I want you to know, and this is something about medicine that is troubling and really good, if you’re looking for a really good doctor or you’re really looking for a really great nurse practitioner provider, you’ve got to realize that fear and being scared into, like, “You could really get in trouble,” that’s not a care plan.

What’s really good is really good information.

And if your doctor is smart or you’re smart, they’re going to be able to give you all the information about what’s really currently happening without throwing in a dose of terror.

It’s just not necessary, right?

If you need hydration, that’s an easy thing to do. If testing is required because you’re not responding like you’d expect, that’s easy to do. If you have a treatment that you’re doing that’s not effective right away, you just shift gears.

I’ve done it a long time. All these things are tiny, tiny problems.

But if you do travel, erythromycin, Imodium, Zofran. I love having this stuff. I have it in my backpack when I travel so that I don’t leave it in my luggage.

When I travel with my family, I make sure that they have it. Any of my patients that are going on a trip, like I said, I don’t get jealous. I get helpful. I help them out.

So if you have diarrhea that is severe and lasts more than a few days, it comes back even though it seemed to improve for a little while, just take care of the hydration.

If you see anything in your stool that’s funky, like blood or anything like that, if you start to spike a fever, you need to get seen, right?

If you have a weak immune system because you’re taking some kind of immune drug, you need to get seen right away.

So if it’s not routine diarrhea, that might be Cyclospora. Listen to your body.

And this is something I’ve said for lots and lots of years to doctors who use our software. I tell them to listen, learn, and love.

This is for you: Listen to your body. Learn its story. Pay attention, right?

I have patients who come in and they, “I don’t know, I think I have a bowel movement like once or twice a week.”

I’m like, “What? That’s terrible.”

“I don’t know, though.”

They just don’t pay attention.

Once you’re my patient, I teach you in a whole bunch of different ways to listen to your body and learn its story.

And when you get a gut feeling, get it? When something’s wrong, then you probably are right. Something’s wrong.

And a really good doctor or provider will be able to spend time with you and kind of help you iron it out. And if it’s nothing, it’ll be nothing, and there won’t be a big deal.

We built Esprē Health to help patients and their doctors learn how to let the body tell the story.

That makes it much easier to get to the root of healing instead of just covering up symptoms. Because when you know the story, you can almost always get to the root of the problem really, really quickly.

And if you need testing, it’s a lot cheaper because you need less testing, and you can actually get to the problem and let the body heal itself.

So I tell our doctors this. I say, “Listen to your patients, learn their stories, and love them with all your heart, and you’ll be unstoppable.”

So if you know anybody who’d benefit from this podcast, who might be entertained by it or not revolted by it, make sure to share it and subscribe if you want more.