You must count yourself exceptionally blessed by all the Nepali Gods if you do not get diarrhoea in Nepal. It is indeed very common among both travellers, foreign residents, and local Nepalese.

There are different causes for diarrhoea and very often even the most stringent eating habits will not ensure safety from this problem.

But never fear, don't feel you have been singled out as many foreigners (and locals) do come down with this. There is help at hand.

From the slopes of Aspen, Colorado to the verdant hills (in summer time) of Banff, Calgary, to the valley of Kathmandu, Nepal, giardia is an omnipresent problem. It is also known as "Beaver Fever" as the faeces of beavers transmit this protozoa (single cell organism). However in Nepal the faeces of man, dogs, and yaks would be higher in the list than beavers! This may cause more protracted diarrhoea than bacteria's. Remember there is significant symptom overlap with bacterial and amoebic diarrhoea. Some travel books say "rotten egg burp" is synonymous with giardia. This is far from the truth as bacteria's very often cause the same kind of burp.

It takes at least 7 days for gastroenteritis, due to giardia to manifest, after swallowing giardia cysts. So, if you get diarrhoea on the second day of your arrival to Nepal, it sure is not giardia ! Travel books love to say 'egg burps' are diagnostic for this problem. Not necessarily true. Bacteria's can also cause 'egg burps'. Responds well to tinidazole. Diagnosis in Nepal is made by history and stool tests.

Treatment:
Tinidazole 2 grams after the evening meal, for one, sometimes 2 days. No alcohol. Be prepared for a feeling of a "whack on the head" as a side-effect of this drug.

In a sense, looking for giardia in the stool under a microscope may be more difficult than looking for clumps of white cells which would be suggestive of a bacterial etiology. Hence, a good exam by an experienced lab technical is essential to rule out giardia and the treatment is obviously different from that of a bacterial diarrhoea. Many times we treat empirically (i.e. just based on the history).

Another treatable cause of diarrhoea (in this land of diarrhoea) requires more diligent observation under the microscope as they are more difficult to detect. There is also the problem of a wrong diagnosis as certain other protozoa bear a strong resemblance. It is important to make the right diagnosis of this mass of protoplasm because, if left untreated, it may invade the liver causing pockets of pus. Believe it or not these are easily and effectively treated (both amoebiasis and the pockets of pus in the liver) but the diagnosis must be made. We usually do not treat this empirically but seek laboratory confirmation.

Can present with malaise, lethargy, fever and diarrhoea. Can cause liver problems as a complication. Treatment is with a longer course of tinidazole followed by diloxanide furoate. Diagnosis in Nepal is made by stool test. However it is generally overdiagnosed in tourists in Nepal.

Treatment:
Tinidazole 2 grams for 3 nights followed by Diloxanide Furoate 500 mgs, 3 tabs daily for 10 days.

Probably better known by its more colourful name, "the blue green algae," this is a very seasonal, common cause of diarrhoea (April-Sept.). Not often seen in winter. The presenting symptom is tiredness out of proportion to the amount of diarrhoea which may go on for weeks to months if untreated.

Scientifically known as cyclospora, seen commonly from April to September, uncommon in the winter. Causes excessive tiredness and diarrhoea. Responds to bactrim, a sulpha based antibiotic.

Cyclospora may be resistant to iodine. So soaking vegetable in iodine may not kill it and you can get infected.

Treatment:
Bactrim D.S. 1 tab 2 times per day for 10 days.
This 'bug' does not respond to the newer antibiotics.

For those of you that continue to have diarrhoea for weeks to months with significant weight loss despite treatment against bacteria, giardia, amoeba, and the "blue green algae", a disease called TROPICAL SPRUE may be the problem. We seem to think that this disease entity may have been under diagnosed in the past. This is a problem you may get even when you go back home and you may need to alert your doctor to this possibility. Treatment with folic acid and tetracycline's may be dramatic.

We advise caution with these medicines. Remember all medicines may have potential side-effects, some very dangerous.

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Notes:

Reports of travellers on return home, suffering from irritable bowel disease (IBD) precipitated by bout/ bouts of gastroenteritis in the developing world is increasingly common You may need to see your gastroenterologist if persistent diarrhoea occurs (Persistent Traveller's Diarrhoea, PTD).

There are plenty of other causes of diarrhoea which are either less treatable or a difficult diagnosis to make. For example: Cryptosporidum, blastocysts, antibiotic induced diarrhoea, tropical sprue, and so on. Worms are uncommon cause of diarrhoea in tourists. Remember the single most important treatment in any kind of diarrhoea is not drug therapy but plenty of fluids. An average adult traveller would need about 4 litres of water to cope with moderate diarrhoea. Then there are packets of electrolytes (Jeevan Jal) that you need to add to the water as you lose a lot of essential electrolytes, e.g. potassium, with the diarrhoea. Just drinking sweet syrupy stuff like coca cola is not a good idea.

Sometimes you may get a high fever for a day before you get the runs: this is not uncommon at all. When you go back home to N. American, Europe, Japan or wherever, you may have to clue your doctor in, especially if you present have diarrhoea there. Tell him/her amoebas and giardias were possibilities where you come from. You will be surprised how many cases of simple giardiasis become the talk of the town (e.g. important case presentations in a Western hospital)

In brief: Nepali diarrhoea has to be treated with due respect (water, electrolytes, drug therapy) but in most cases there would be no reason to cut short your trip on account of this problem.