'Bali Belly' & traveller’s diarrhoea
It may be called Bali Belly, the Rangoon Runs or Montezuma’s Revenge but it can happen anywhere!
So what is it, and what is happening? Why does it happen when travelling? What are the long-term consequences? And, most importantly, what can you do about it?
Sometimes, it’s good to look at the local remedies for help.
Bali Belly/traveller’s diarrhoea - what is it, and what can you do?
This post covers:
What is Bali Belly/travellers' diarrhoea?
Digestive changes while travelling
Most common causes of Bali Belly/travellers’ diarrhoea
Could it be food intolerance or allergy?
Potential long-term consequences?
Conventional medicine treatments?
How local natural medicines can help
FAQ’s
What is Bali Belly/travellers' diarrhoea?
Bally Belly is a term for any kind of digestive disruption that can include symptoms of diarrhoea, vomiting, bloating, reflux and abdominal pain, generally experienced while on travelling. It commonly occurs in countries where the drinking water is untreated or where food hygiene standards may be lower. It’s however, unfair to call it Bali Belly when it can occur anywhere in the world. So whilst it’s a commonly recognised term, it will be referred to as travellers' diarrhoea or digestive upset for the rest of this article..
Most cases of travellers diarrhoea or digestive upset are as a result of accidentally ingesting microbes that alter the makeup of species in the microbiome causing symptoms such as:
Abdominal bloating and distention
Abdominal discomfort, cramping and/or pain
Nausea and vomiting
Urgency to use the bathroom
Frequent, loose, or watery stools (diarrhoea)
Change of colour or smell of stools
Mucus, or frothiness in stools
Smelly or excessive flatulence
Excessive burping
Reflux, heartburn or indigestion
Sweating or mild fever
Fatigue, lacking in energy
Malaise - generally feeling unwell, tired, and/or moody
These changes in the microbiome are called dysbiosis
Dysbiosis is the term given “when the growth of potentially pathogenic microbes and pathobionts overtake their beneficial counterparts, leading to alterations in the metabolic activities and metabolic byproducts of the ecosystem leading to harmful consequences” (Jason Hawrelak 2023)
Digestive changes while travelling
You don’t necessarily need to eat or drink contaminated food or water while on holiday to experience disruption to your digestion or bowel habits. Several other factors can influence altered digestion.
Travelling can be stressful - even when it’s also relaxing. You’re out of your comfort zone, transport gets delayed, people have expectations (the ones you are travelling with and those you meet along the way), and sometimes things just don’t go to plan. Even the most relaxing holidays can have their stressful times causing digestive imbalances.
Sometimes, it may be a combination of factors causing digestive upset. Here are a few of the common causes:
Stress/anxiety - The stress response known as ‘fight, flight or freeze’ is our body’s way of keeping us safe by prioritising its resources. One way is by stopping production of hydrochloric acid in the stomach, the secretion of digestive juices and slowing of peristalsis (a wave of muscular contractions in the digestive tube that pushes food through), because you’re not going to need to digest food if you have to run from a tiger, right?
Ordinarily, hydrochloric acid is one of our first lines of defence protecting the digestive tract from pathogens that can disrupt our microbiome. This can mean that any microbes consumed (good, bad or otherwise) can pass through the stomach without its usual acidic defences to kill them.
Digestive juices are necessary for breaking down foods to allow nutrients to be absorbed in the small intestines. Without these juices, undigested foods/nutrients can travel to the colon where they wouldn’t usually be. These nutrients feed opportunistic microbes, alter the pH and disrupt the microbial balance.
Slowed peristalsis means the food takes longer to pass through the gut allowing chemicals your body is trying to get rid of, to be reabsorbed back into the bloodstream. Problematic if you’ve taken in a pathogen or its toxins. Your body’s response is then diarrhoea and/or vomiting - to get it out! So, the symptoms in this case …or the end result (pun intended!) may be a little constipation, followed by a lot of diarrhoea. This is why sometimes, symptoms can change rapidly from one to another as the microbiome changes.
Drinking less water and sweating more can happen in countries where the water is unsafe and it is easy to become dehydrated, contributing to constipation altering the microbiome and causing symptoms of bloating, burping, abdominal pain, griping, and flatulence.
Dietary changes - sometimes a particular food gets blamed as being ‘off’ or contaminated, but that may not necessarily be the case, you may be:
eating new/unfamiliar foods that contain molecules your body doesn’t tolerate well, or,
eating more fatty, spicy, sugary, foods, more meat, or high-histamine foods,
consuming alcohol,
eating less of the good foods you normally eat.
The microbes in your gut change with the food they’re provided - and they do this in as little as 4 hours. Generally, symptoms of the above changes would be fairly mild and not enough to cause severe symptoms of traveller’s diarrhoea on its own, but it can leave your microbiome vulnerable to pathogens or parasites if you do ingest them.
Food intolerance or allergy - you may eat a food that is perfectly well-cooked and prepared, but you have an allergy or intolerance that you’re unaware of.
Histamine - histamine is a signalling molecule used by our bodies and made by bacteria in our gut and some foods. It stimulates hydrochloric acid to be produced in the stomach (amongst other things) but too much histamine can be associated with
headaches, migraines, allergies, hives, sneezing, wheezing, asthma, eczema, heart palpitations/racing,
It occurs in foods like cheese, wine, vinegars (or anything that contains it), kombucha, kimchi, sauerkraut, pickles, and particularly fish and meats that are not super fresh (like caught the same day).
Anyone with hay fever or allergies will be familiar with the effects of too much histamine. Our gut bacteria make histamine and we produce enzymes (DAO & HNMT) to break it down. When we ingest or produce more histamine than we can break down it can cause an allergic reaction
Change to routine - You might be eating at different times of the day. The body’s circadian rhythm is set not only by our sleeping patterns but our eating patterns as well. If you find you are not eating breakfast in the morning, or starting the day with a coffee but no food you can raise your stress hormones which goes back to point one above - stress. Often people will say this makes them feel ‘energised’ and this can be true, but is still an elevated nervous system state that can impact the gut in the same way as stress. Similarly, eating late at night, or eating heavy meals before bedtime can impact the way your body digests it.
Grazing all day? If you’re eating more often, snacking in between meals you may stop the migrating motor complex (MMC) - a stronger wave-like contraction that occurs every 90 minutes - but, only between meals - and is like a cleaning process. Poor/no MMC function is often associated with the development of SIBO (small intestinal bacterial overgrowth), or SIFO (small intestinal fungal overgrowth) as it is required to help control bacteria and fungal growth in the small intestines.
Intense exercise - Exercise is great at improving health in many ways and regular exercise has even been demonstrated to improve health by increasing the diversity and abundance of species of the microbiome. Intense exercise, however, e.g. marathon running, long-distance swimming, or long, difficult hiking etc. can alter the microbiome negatively by raising stress hormones, reducing hydrochloric acid production and slowing peristalsis. Even though intense exercise can feel good, it is still an elevation of the nervous system - your body doesn’t distinguish good stress from bad stress!
Most common causes of Bali Belly/travellers’ diarrhoea
Bacterial infections make up approximately 50-80% of traveller’s diarrhoea with Escherichia coli (E. coli) a primarily an enterotoxigenic strain (i.e. a toxin to the gut) is one of the most common bacterial causes of traveller’s diarrhoea. Other bacterial causes include Salmonella and Shigella species and Campylobacter jejuni. Fever, abdominal pain, urgency, watery diarrhoea and vomiting usually accompany these infections. These infections are generally self-resolving in healthy people.
Viruses such as norovirus and rotavirus can be responsible in an estimated one-third of all travellers’ diarrhoea cases. A viral infection can be easily passed from one person to another and is usually self-resolving in generally healthy people. Digestive symptoms can occur with viruses such as COVID which has been shown to alter the microbiota, during and after infection.
Parasites such as Entamoeba histolytica, Giardia intestinalis and Cryptosporidium parvum are common causes of diarrhoea. These infections can last longer than a few days and may cause a bloody stool. They generally can be more difficult to eradicate than bacterial infections. Some of these parasites are only recently being considered as potentially having some beneficial aspects, when in appropriate numbers, and problematic when allowed to proliferate. However, more research is required to understand the interactions fully. In the meantime, it is common that parasites are not fully eradicated in short term or poorly targeted treatments and in a disrupted microbiome (such as one on antibiotics) can multiply to problematic levels, long after the holiday is over.
Medications. Most commonly any antibiotics can cause diarrhoea as they are non-selective antimicrobial agents. This means that while they may kill the pathogenic bacteria, they may also kill the healthy microbes as well. More importantly, they can leave space that opportunistic species will proliferate into this gap - in the same way as when you weed your garden and a week later it’s full of weeds. Some antibiotics have been shown to make some of our normal microbes permanently extinct, so whilst it can be a life-saving medicine, it shouldn’t be taken unnecessarily. Other medications such as proton-pump inhibitors (antacid medicines), and antihistamine medications can alter the types of species that make up the microbiome. Other drugs such as Metformin, laxatives, and anti-inflammatories e.g. non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, aspirin, Nurofen etc. can all alter the microbiota.
Unknown causes when the gut experiences unusual new species of microbes it can sometimes react by trying to rid the body of it, even if it is a benign microbe. This can sometimes result in diarrhoea, short-lived and self-resolving.
Environmental chemicals - Pesticides, herbicides such as glyphosate (Roundup), Triclosan, BPA, and phthalates, can significantly impact the microbiome.
Food additives - emulsifiers such as polysorbate-80 and carboxymethylcellulose have both been shown to diminish beneficial species and increase inflammation-causing pathogenic microbiota species and cause low-grade gut inflammation.
Artificial sweeteners - Sucralose, aspartame, saccharin, & acesulfame potassium have all been shown to cause metabolic abnormalities (including weight gain) and damage the microbiota.
Could it be food intolerance or allergy?
In a word, yes! And, so often this is the case. There are some really common offenders, but equally, you can be intolerant or allergic to pretty much anything.
If you are reacting to a new food while your friends, eating the same foods don’t then you may have a food intolerance. This isn’t an allergic reaction as such, as a different part of the immune system may be reacting. In allergy the immunoglobulin IgE is often responsible, whereas in food intolerance it may be an IgG reaction.
If you have had some digestive disruption before travelling, then you possibly have some intestinal hyperpermeability (commonly referred to as ‘leaky gut’) which can lead to developing intolerances and allergies to foods that previously you’ve had no issue with, or to new foods.
What are the potential long-term consequences?
Naturopaths will often ask if you have ever travelled, and if you did, were you sick. This is because sometimes, there can be long-term consequences of travellers’ diarrhoea. They include:
Parasites, if left untreated/unsuccessful treatment
Ongoing, unresolved dysbiosis
And/or, a vulnerability to further dysbiosis when combined with:
antibiotic treatments taken for travellers diarrhoea, or other illnesses
triple therapy for H. pylori treatment
other medications, given for illnesses other than digestive ones
stress, or trauma experienced while travelling
other factors
This can lead to;
ongoing digestive disruption such as loose stools, urgency, abdominal pain and bloating, reflux and indigestion, constipation or fluctuating symptoms,
IBS, SIBO, gastritis
sensitivity/intolerance to foods previously well-tolerated
More frequent infections and illnesses
The reactivation of latent viruses such as Epstein-Barr Virus (glandular fever), Cytomegalovirus, or any of the other human herpes viruses
Development or flare of auto-immune conditions
And, if allowed to continue long-term may be associated with the development of a range of digestive and non-digestive conditions. As the colonic microbiome plays an important part in regulating the immune system, disruption to the types, balance, ratio, diversity and abundance can impact our ability to ward off disease and infection. Dysbiosis is believed in recent research to play a key role in the development of most chronic and degenerative disease states, including:
Digestive conditions:
Non-alcoholic fatty liver disease, Alcoholic liver disease, antibiotic-associated diarrhoea, chemotherapy-associated diarrhoea, radiotherapy-associated diarrhoea, Clostridiodes difficile-associated disease, celiac disease, Crohn’s disease, diverticular disease, IBS, IBD, and, liver cirrhosis
Non-digestive conditions
Anxiety, asthma, Alzheimer’s disease, eczema, autism, chronic kidney disease, kidney stones, multiple sclerosis, Parkinson’s disease, Type 1 and Type 2 diabetes, rheumatoid arthritis, chronic fatigue syndrome, depression, metabolic syndrome and obesity,
Some species of bacteria release a toxin into circulation when they die, known as lipopolysaccharides or endotoxins. These toxins have been associated with many diseases, particularly neurodegenerative conditions such as dementia, Alzheimer’s and Parkinson’s diseases, endometriosis, and many other conditions characterised by chronic inflammation.
How does conventional medicine treat travellers' diarrhoea?
Before leaving home, the Australian government health recommendations focus on prevention and hygiene, washing hands, and caution around drinking water and food that may not have been prepared or stored well. Whilst there is no specific vaccination for traveller’s diarrhoea, recommendations are made to be vaccinated against cholera as this may reduce the incidence of traveller’s diarrhoea.
Diagnosis is most often made by symptom picture and sometimes stool testing for specific parasites may be requested, if diarrhoea persists.
Treatment strategies include electrolyte formulas/oral rehydration solutions such as Hydralyte, or plain water, to prevent dehydration, antibiotics, anti-nausea drugs, and dietary recommendations such as avoiding dairy, spicy foods, and alcohol, and avoiding the use of antidiarrheal medicines if experiencing fever.
Antibiotics may be given as a first line of treatment, without testing and only when this treatment is unsuccessful is testing or, treatments for other pathogens are tried. This can contribute unnecessarily to further disruption of the microbiome eliminating beneficial species, and contributing to antibiotic resistance in the community.
In countries like Bali, intravenous vitamins, drugs and nutrients are available in some clinics and when administered appropriately, by suitably qualified practitioners, they may assist in speeding recovery.
However, when you are in a foreign country it may be difficult to access treatment when it is most needed, as often language and unfamiliarity can be a barrier. For this reason, many people do not seek treatment until they return home.
How can local natural/traditional medicines help?
Traditional medicines are available in all countries when you know where to look, and it is worth looking at these treatments to help relieve symptoms and aid in a speedy recovery. Science is catching up and validating much of the valuable and long-held knowledge of herbal medicines, demonstrating what herbalists and traditional healers have known for centuries.
In Bali and Indonesia, traditional treatment of diarrhoea, nausea, bloating, vomiting and excess flatulence may include:
Guava leaf tea - an astringent tea used traditionally in many Asian countries to reduce symptoms of diarrhoea and for assisting in treatment of dengue fever. Research shows that Guava leaf contains a range of flavonols (morin, morin-3-O-lyxoside, morin-3-arabinoside, quercetin, and quercetin-3-O-arabinoside) as well as a host of other beneficial nutrients such as kaempferol, hyperin, ECGC, gallic acid and caffeic acid (+ many more). Guava leaf is also thought to be beneficial as an antimicrobial, antidiabetic, antioxidant, and to assist in lowering cholesterol and support liver function. As the fruit also contains many of these constituents (though, in differing amounts) it may also be beneficial when eaten or drunk as juice.
Dried Mangosteen husk tea - used traditionally in Ayur Vedic medicine in India, and throughout S.E. Asia as an antimicrobial, a meta-analysis of 30 studies found it similar in effectiveness as an antimicrobial agent to commercially available antibiotics (p=0.05) against specific bacterial, fungi and mycobacterial species. Considered a ‘superfruit’ in Asian cultures, the fruit and husk are both considered a general health tonic, and the husk is also used as a dye and for treatment of skin conditions, with potential for its use in methicillin-resistant Staphylococcus aureus treatment.
Turmeric or Temu Lawak (a paler variety of turmeric) as a tea, turmeric or Curcuma longa is the orange coloured spice often found in Indian cooking, and many people are familiar with the anti-inflammatory benefits of curcumin, its main active molecule. Temu Lawak or, Curcuma xanthorrhiza is also known as Javanese Turmeric featuring highly in Indonesian cuisine, medicine, and culture, it is the paler yellow cousin of turmeric with many similar constituents and actions. It is worth mentioning that most people are only aware of one constituent curcumin as it is the only one that has beenwell-studied, it is however, only one of many curcuminoids found in all forms of turmeric (yes, there are more than just these two!). Curcumin has been demonstrated to be anti-oxidant, anti-inflammatory, anti-microbial, protective of the brain, heart, and liver function, it has properties that may reduce cancer cell development, and polyphenols which feed beneficial microbiota.
Soursop fruit, juice, bark and leaves as a tea, are used traditionally as an antiparasitic, antidiarrheal medicine, and studies in Nigeria show promise as a simple and accessible treatment for watery diarrhoea in children under 5, one of the biggest killers of children in the world.
Ginger, as tea (fresh slices in hot water), or can be found in local supermarkets as hard candy to help reduce nausea, bloating and abdominal discomfort.
Jamu - a traditional tonic drink (and, also the name of traditional medicine) with a variety of recipes made from a base of turmeric, temu lawak, and one or more varieties of ginger. It is taken as a general health tonic, for pain relief, and as a remedy for almost any illness or condition. It is considered to be the foundation of good health and anti-ageing by many Javanese and Balinese people.
There are, of course, many others. As with most herbal medicines, there are always many alternatives and so the ones at hand are often the ones chosen, or by taste preference, preparation method or other considerations may determine the most appropriate..
Caution should always be exercised, as whilst these are natural they are still medicines and can interact with pharmaceutical drugs, and other herbal medicines or be harmful in incorrect dosage. In Australia, the Therapeutic Goods Administration ensures the quality and safety of all supplements and herbal products and is generally considered to have the most stringent standards. Particularly outside of Australia (including the USA) some online supplement products, when tested, were found to be of inferior quality, adulterated, contaminated or unsafe so it is important to be sure that the product you are purchasing is safe. Generally, single, dried herbs drunk as teas are the safest way to take these medicines however, always seek the guidance of a qualified practitioner to ensure this is safe for you. A naturopath familiar with these herbs may be able to assist you.
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Frequently asked questions -
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Bali Belly is really an unfair term, when it can occur anywhere in the world - even in your own home. It is a term that covers any type of digestive upset, though usually an acute bout of diarrhoea and vomiting with onset within 12 hours of eating or drinking. Most often it occurs as a result of consuming food or water that is contaminated with bacteria, viruses or parasites and this happens more easily in countries where food or water standards are low. Using untreated water for teeth cleaning can be a common factor.
When travelling there may be a myriad of different factors which can contribute directly, or indirectly to developing traveller’s diarrhoea or other digestive disturbances. If your gut microbiome had any disruption prior to travel, you may be more susceptible to parasites or dysbiosis (the disruption to the number, ratio or type of species of the colon which can lead to detrimental effects). Eating new and unfamiliar foods, changing the way you eat, eating less of the healthy foods you would normally eat, drinking more alcohol, or consuming foods that you have an allergy or intolerance to, can all cause dysbiosis. Taking some kinds of medications, such as antibiotics, antacids like Nexium, Gaviscon or Somac, Metformin and many other common pharmaceuticals can impact the gut microbiome and contribute to dysbiosis.
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It can depend on the cause of the diarrhoea, and what is available to you at the time. Most often it is self-resolving and you just need to manage symptoms. As with any diarrhoea and vomiting the loss of fluid means it’s important to maintain hydration with clean, clear, filtered water and electrolyte solutions. Fresh, natural coconut water with a pinch of natural sea salt or Himalayan salt can be a good substitute for electrolyte solutions, if unavailable. If this continues for longer than 24 hours, or you become dehydrated it is important to seek emergency medical care.
Antibiotics are often given as a first line treatment, however, this may only give temporary relief but further disrupt the microbiome after recovery, causing ongoing digestive problems. Antibiotics can be life-saving medications, when used appropriately and should therefore, only be prescribed when necessary.
Other natural remedies may be sought, and if you are overseas in Asian countries some traditional local fruits and herbal teas can help reduce the symptoms, and speed recovery times.
These include:
Guava fruit, or guava leaf tea,
Soursop juice, fruit or leaves as tea,
Turmeric, or it’s close cousin Temu lawak, as a drink, or tea
Ginger or mangosteen husk tea.
In Australia some natural strategies for reducing diarrhoea can include:
Specific bulking fibre supplements like slippery elm powder
Specific strains of probiotics, such as Lactobacillus rhamnosus GG, or Saccharomyces boulardii cerevasiae (SB) - particularly during or after antibiotic use.
Astringent herbs, as tinctures - such as Rheum palmatum - Turkey Rhubarb (low dose only), Barberry, Blackberry or Cranesbill.
Or, as tea -
Raspberry leaf,
Matcha green tea
Chamomile
Marshmallow root
Chronic, or persistent diarrhoea should always be investigated for its underlying cause. If symptoms persist, have it investigated by your doctor or naturopath.
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The stress of travel can disrupt the microbiome and cause alterations in bowel movements, or leave you more susceptible to pathogens, parasites or pathobiont proliferation (where a normal microbial species goes from healthy and beneficial numbers, to unhealthy and detrimental numbers).
Medications, alcohol consumption, change to diet, changes to sleep and mealtimes can change the circadian rhythm, unfamiliar food colours, preservatives and additives, pesticides, herbicides and other environmental chemicals can all instigate changes in the microbes in your gut.
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There are many different types of parasites, they have been a part of human existence for all time. Some are fairly benign with no symptoms, some types of worms are thought to stimulate the immune system in a way that actually primes the immune system and helps to regulate it against allergy (don’t try this at home!). Some cause nutrient depletion, by essentially eating our food before we can, and others can stimulate the body to try very hard to expel them. These are the ones that generally cause problems.
Unless you have a type of worm that causes itching to the rectum at night time, or is seen in the toilet bowl it can be hard to be sure if you have a parasite. The best way to know if you have a parasite is with specific stool testing, targeted according to where you have been and what is most likely.
Some species of microbes are suspected of being part of our normal microbiome with their numbers kept in check by our other microbes, in a healthy balanced gut, but when things get out of balance these opportunistic bugs then take over and become a problem.
There are many effective herbal antiparasitic treatments that, used as targeted and short-term therapies, can be really effective at managing parasites while maintaining a healthy microbiome.
Book for a free discovery call if you’d like to discuss how I can help.
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Yes! Whilst naturopaths do not specialise per se, we do have areas of interest that we work with often. Julie Forrester is a self-confessed microbiome nerd currently completing her masters in Advanced Naturopathic Medicine in Human microbiome and health stream. She’s also a woman who has had her own experience of Bali Belly, and is currently writing a reference guide for other naturopaths and herbalists on Traditional Indonesian and Balinese herbal medicines.
She works with people of all ages and stages with digestive issues.
Working online via Telehealth, Julie is the gut health naturopath that is always ‘near you’ (especially helpful if you are sick while on holidays) - just a click away, as long as you have a device, the internet and the desire to feel normal again!
Book for a free discovery call here today, and find out if she is the right practitioner to help you.
