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Gastroenteritis and Food/Water Borne Diseases

Gastroenteritis is very common in Indonesia due to ineffective public health controls and poor hygiene standards. The overall incidence of food and water borne disease is very high compared to the Western world. The traveler or resident needs to take great care and personal responsibility for maintaining a supply of safe food and drinking water due to this high risk of "food poisoning" with bacterial and parasitic diseases such as cholera, typhoid fever, dysentry, amoebiasis and giardiasis.

Acute gastroenteritis is caused by viruses, bacteria and parasites. The primary manifestation of gastroenteritis is diarrhea, but it may be accompanied by nausea, vomiting, and abdominal pain. The vomiting usually settles in a day or so. The diarrhoea may last for up to 10 days, but usually lasts only 2 or 3 days. If there is fever, or blood and mucous in the stools it is more likely to be contagious. Gastroenteritis is contagious as the organism lives in the gastrointestinal tract, so it is important to wash hands thoroughly after going to the toilet and before preparing food.

Gastroenteritis may occur at any age. In a normal healthy person, a case of gastroenteritis is no more significant than a common cold. However, prolonged bouts of vomiting and diarrhea can lead to dehydration and disruption of important body chemistry such as sodium, chloride and potassium. The younger the child, the greater the danger. Chronic diseases such as diabetes mellitus or kidney problems may put you at additional risk for complications from gastroenteritis. The morbidity and mortality are much higher in the very young and the very old.

If the illness is only mild, you may not need to see the doctor and you can follow the dietary advice below. It is important to consult your doctor if: diarrhoea is profuse, eg. above 8 watery stools a day, persistent vomiting, severe abdominal pain develops or any of the following danger signs are present;listlessness, difficulty in waking up, sunken eyes, very dry skin and tongue, pallor, passing little or no urine. If these signs are present, contact your doctor without delay, as you or your child may need admission to hospital.
If you do see a doctor, it is common in Indonesia for doctors to prescribe antibiotics. In many cases people will improve without antibiotics but in some cases they are necessary. If the diarrhoea is bacterial, antibiotics may shorten the course of the illness. It is always useful to ask your doctor to do a stool test and culture so that the cause of gastroenteritis can be identified and the treatment targeted. For instance if it is amoeba, an antiparisitic drug such as Flagyl should be used, while if it is a bacteria like typhoid or dysentery, it can be tested against various antibiotics to see which is the best antibiotic.

Doctors in Indonesia often prescribe other medications, which harden your bowel movements, or antispasmodic drugs that slow down bowel activity. Though in some circumstance (e.g. when flying, important meetings) they can be useful to control the symptoms, they do not shorten the illness. Anti-emetic drugs (Primperan) are also often prescribed to stop vomiting. In most cases this is not necessary as vomiting will settle by itself and as there is a chance of a reaction to the drug (oculogyric crisis) these drugs should be avoided especially in children.

What Can You Do?

Stay at home and rest until symptoms subside. Avoid solid foods until vomiting stops. As soon as you are able, take small amounts (about 1 oz. every 15 minutes by the clock) of clear liquids such as tea, ginger ale or broth. If vomiting recurs, wait 1-2 hours before trying clear liquids again. Once you are retaining fluids without difficulty, try to increase the amount you take each hour, gradually (or decrease the amount of time between sips).
After 24 hours without nausea, vomiting or diarrhea, or if hungry and not vomiting, you should try dry toast, saltines, or white rice, with jelly or honey for energy. Progress to soft, mildly flavored foods that are low in fiber until you are back to good health. You may wish to use the "BRAT" diet as a guide: Bananas - Rice (white) - Applesauce - Tea and Toast.
Many people can temporarily lose the ability to digest milk sugar for 1-2 weeks after an episode of gastroenteritis. Avoid milk products, oils and spices until you are feeling better - and resume them gradually, as tolerated. A suggested diet for children is given below.

Day 1

Give fluids a little at a time and often (eg. 50 mL every 15 minutes if vomiting a lot). A good method is to give 200 mL (about 1 cup) of fluid every time a watery stool is passed or a big vomit occurs.

The ideal fluid is Gastrolyte, a glucose and mineral powder that you can obtain from your pharmacist and make up according to the directions on the packet.

Alternatives to Gastrolyte are:
lemonade (not low calorie) 1 part to 4 parts water
sucrose (table sugar) 1 teaspoon to 120 mL water
glucose 1 teaspoon to 120 ml water
cordials (not low calorie) 1 part to 6 parts water
Warning: Do not use straight lemonade or mix up Gastrolyte with lemonade or fluids other than water.

Days 2 and 3

Reintroduce usual milk (or formula) diluted to half strength (i.e. mix equal quantities of milk or formula and water).

Do not worry that your child is not eating food. Solids can be commenced after 24 hours. Start with bread, plain biscuits, jelly, stewed apple, rice, porridge or non-fat potato chips. Avoid fatty foods, fried foods, raw vegetables and fruit, and whole grain bread.

Day 4

Increase milk to normal strength and gradually reintroduce the usual diet.If diarrhoea persists for a long period of time, especially if accompanied by weight loss, fatty stools (that stick to the toilet and are hard to flush), and a low Vitamin B12 (on blood test), this requires further investigation by your doctor. This could be a sign of malabsorption, which can be caused by a variety of diseases including tropical sprue, giardiasis and coeliac disease.

Our sincere appreciation goes to Dr. Andrew Jeremijenko of VICO for his generous contribution of this article!

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