Stomach Trouble

Living Well in Myanmar

The trouble with stomach trouble

In the last few months many of my friends and colleagues have suffered from intestinal troubles, sometimes for a few days and often for several weeks.  They have tried different types of treatment, from self-prescribed dietary changes and therapies to visits with doctors.  Their interactions with doctors have often been confusing and frustrating.  Not surprising, given that a person’s symptoms don’t reliably point to a specific cause of belly pain, and diagnostic tests have difficulty providing a definite answer.  Doctor and patient may face a series of trial-and-error treatment attempts as the approach to intestinal disease becomes more art than science.

Let’s assume most of the GI episodes we’re talking about are from new infections.  We see these increase during rainy season in Myanmar as the environment becomes more hospitable to viruses, and food hygiene and water quality become more prone to bacteria and parasites.  People suddenly have abdominal pain, diarrhea, fever, and fatigue.  What to do next?  Antibiotics?  Probiotics?  Avoid some foods?  Increase some other foods?  See a doctor?

I try to start by remembering that the body often does a good job of healing itself --diagnostics and medicine may not be necessary.  However it remains important to look for reasons to do testing or offer empiric treatments.  Diarrhea is medically defined as watery poop more than 3 times per day.  If this is happening doctors should use a physical exam to determine the need for Oral Rehydration Salts or IV therapy.  Checking a stool sample is usually only needed if the diarrhea has blood or mucus in it, if the patient has high ongoing fever, or if the diarrhea lasts more than two weeks.  A seriously ill person may need more labs checked and possibly hospitalization. 

Using medications is a tricky decision.  In developed countries most diarrhea is caused by viruses for which antibiotics are not useful.  At the same time, medical guidelines recommend trying a course of antibiotics for “traveler’s diarrhea” in developing countries.  Readers of this column have lived in Myanmar for different lengths of time, and there is no guideline for who is a “traveler”.  In certain bacterial infections antibiotics could actually be harmful.  Meanwhile the illness may be the result of a parasite (ie, Giardia) rather than bacteria, in which case a different type of medicine is needed.  So sorting out who is right for antibiotics or antiparasitics is complicated and what I mean by the art of medicine. 

Antidiarrheal medicines are usually safe.  As a long as patients have no fever or blood/mucus in the stool, I’m comfortable with them using Imodium (Loperamide) or Pepto-Bismol/Kaopectate (bismuth subsalicylate) on their own.  Some of my friends are attracted to the theory of a probiotic being able to regulate gut flora during GI disease.  As a western doctor I haven’t seen sufficient medical evidence to recommend probiotics for acute diarrhea (although there are some other data-proven indications for probiotics).  Also I worry that exposing a compromised intestinal epithelium to a high load of any bacteria could be problematic, particularly if the illness is parasitic rather than bacterial.

As for food consumption while suffering from abdominal symptoms, it is generally felt that trying for a balanced diet with plenty of water is best.  A sick person might struggle with this.  I recommend eating as well as possible, trying to get nutrients and calories from whatever feels edible.   For sickness that begins to stretch into weeks, you might have to guess which foods/spices are giving your temporarily weakened GI tract ongoing problems.  Avoiding dairy products and non-familiar foods for a period of time is a good place to start.

Hopefully you're now not more confused.  The process of getting well after a GI infection is variable, requires some guesswork, and generally goes better if you're able to communicate well with your doctor.  The gut is intricate and sensitive.  Give it time to heal.

gelsdorfMD@gmail.com  © Christoph Gelsdorf 2013