Persistent Diarrhea and Flatulence After Travel to India

A 45-year-old man is evaluated after backpacking in India for the previous month. He reports 2 weeks of loose stools, initially four to five episodes daily, associated with anorexia, malaise, weight loss, flatulence, and abdominal cramping with defecation.

Over the last 3 days he has developed prominent bloating and abdominal distension after drinking milk or eating dairy products, followed by urgency to pass stool. He has mild nausea but no fever. Earlier stools were watery, but after taking ciprofloxacin from a local pharmacy for 5 days, the frequency decreased slightly and the stools became mushy, greasy, and foul-smelling.

During the trip he frequently stayed in budget hostels, drank beverages with ice, ate street food, and on several long travel days refilled his bottle from untreated tap water because he could not find bottled water. He recalls one overnight trek when he also drank water that had only been filtered through a cloth. Several other travelers he met developed brief diarrheal illness, but his symptoms persisted after theirs resolved.

He is 180 cm tall and now weighs 72 kg, down about 4 kg from baseline. On examination he is not dehydrated and has only mild diffuse abdominal tenderness. The remainder of the physical examination is normal. Stool testing later shows positive reducing substances.