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CPD: The returning traveller

Learning Objectives

This module brings you all the latest on managing illness in the returning traveller, including:

  • Distinguishing different causes of traveller’s diarrhoea
  • When to use antibiotics
  • How to investigate potential malaria
  • Advising patients about Zika virus


Dr Naina McCann is a specialist registrar in infectious disease at University College Hospital London and Dr Anna Checkley is a consultant in tropical and infectious diseases at the Hospital for Tropical Diseases, London.

Case 1

Miss B, a 25-year-old backpacker, attends her GP with diarrhoea and abdominal bloating. Her symptoms started three weeks ago when she was travelling in India. She returned to the UK five days ago and her symptoms have continued. She is worried as she thinks she may have lost some weight.

What is the most likely diagnosis, and what are the most likely causes?

The most likely diagnosis is travellers’ diarrhoea.

Travellers’ diarrhoea is defined as an increase in frequency of bowel movements to three or more loose stools per day occurring during, or within 10 days of, a trip abroad, usually to a less economically developed region.1

The various causes of travellers’ diarrhoea are listed here:

Presentation Pathogen Specific features

Acute watery diarrhoea

Enterotoxigenic E.coli (ETEC)

Most common cause of travellers’ diarrhoea. Abdominal cramping common


Enteroaggregative E.coli (EAEC)

May be persistent



Fevers common, cramps, vomiting

Acute bloody diarrhoea


Fevers, cramps, tenesmus, may be persistent. MSM is risk factor



Fevers, cramps


Enteomoeba histolytica

Lower abdominal pain, tenesmus, fevers, can be chronic

Acute diarrhoea with vomiting


Rapid onset, vomiting predominant



Cramps, fever

Chronic diarrhoea (>14 days)


Bloating, flatulence, steatorrhoea




Other possible causes should also be considered:

  • Clostridium difficile (C. diff) if recent antibiotic use (may be bloody).
  • HIV if history suggests possible exposure.
  • Non-infective causes (e.g. coeliac disease, hyperthyroidism).

The most likely cause here is parasitic traveller’s diarrhoea as the symptoms have lasted more than 14 days.

What investigations will you request at this point?

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