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Practice Rational Testing

Investigation of diarrhoea in a traveller just returned from India

BMJ 2011; 342 doi: (Published 26 May 2011) Cite this as: BMJ 2011;342:d2978
  1. Nicholas A Zwar, professor of general practice1,
  2. Adrienne Torda, senior staff specialist 2
  1. 1School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2052, Australia
  2. 2Prince of Wales Hospital, Barker Street, Randwick, NSW 2031, Australia
  1. Correspondence to: N A Zwar n.zwar{at}

The causes of diarrhoea in people returning from travelling can be infective and non-infective, and the duration of symptoms is an important factor in identifying the cause. The article outlines the appropriate investigations

Learning points

  • The likely cause of travellers’ diarrhoea depends on the duration of symptoms

  • Bacteria, in particular enterotoxic Escherichia coli, are the most common pathogens found in travellers with acute symptoms (less than two weeks’ duration)

  • Stool microscopy for ova, cysts, and parasites and culture (ideally three specimens) form the key investigation in a patient who has just returned from travelling and has diarrhoea, although a causative agent is often not found

  • If symptoms persist, investigate for less common pathogens, such as parasites, and for non-infective causes

A previously well 21 year old student who has just returned from a three week trip to India presents with diarrhoea. In her final week there she did volunteer work in a rural village. Her symptoms started five days ago, with three to four unformed motions a day, fever, and cramps. Her fever has resolved but loose motions continue. A physical examination is normal except for active bowel sounds.

What is the next investigation?

Definitions differ slightly, but classic travellers’ diarrhoea is usually defined as three or more unformed stools within 24 hours passed by a traveller and accompanied by other symptoms—most often cramps, nausea, fever, blood with the stools, vomiting, and faecal urgency. More than 15 million travellers are estimated to experience diarrhoea each year1; developing countries in particular are high risk destinations, with rates of diarrhoea between 20% and 90% for each two week stay, usually in the first week of travel. Travellers’ diarrhoea often disrupts planned activities.1

Though travellers are often told to “boil it, cook …

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