Gastrointestinal disorders

Information on pre-travel preparation, tips to stay healthy abroad and links to useful resources for travellers with gastrointestinal disorders

Key messages

• Travellers with gastrointestinal disorders should check their destination, available medical facilities and access to care, prior to travel.
• Comprehensive travel insurance is essential to include cover for all medical conditions.
• Treatment of inflammatory bowel disease may involve immunosuppressive medication, increasing the risk of infection for these travellers.
• Those whose symptoms have recently relapsed should ideally delay travel until symptoms have improved and their condition is stable.
• Relapse or worsening of symptoms due to infection, change in diet or decreased compliance with medication are all potential risks associated with travel.
• Travellers need to plan how to manage an emergency overseas, such as a flare-up of an inflammatory condition, loss of medication, or equipment.
• Carrying a 'Can't Wait Card' can help explain the need to use a toilet urgently.

Overview

Gastrointestinal (GI) disorders describe a wide range of conditions which vary in severity from relatively mild to severe and disabling:

• Inflammatory Bowel Disease (IBD) mainly refers to Crohn's disease and ulcerative colitis. Both are autoimmune disorders, where the body's immune system damages healthy tissue of the gut. Treatment of IBD may include medications which suppress the immune system such as high dose steroids, azathioprine, methotrexate or biologic agents and JAK inhibitors [1, 2].
• Cancers of the gastrointestinal system (e.g. bowel or stomach cancer) may result in immunosuppression from medication or treatments such as radiotherapy or chemotherapy.
• Immunosuppression from medication will increase the risk of infections. Vaccines may be less effective or may be contraindicated in this group. Additional advice for travellers who are immunosuppressed is available.
• Surgical treatment for both IBD and cancers of the GI tract can involve removal of parts of the digestive system. This may affect the absorption of medication such as malaria tablets. Surgical treatment may also involve the formation of a stoma or ileostomy.
• Coeliac disease (an autoimmune disorder) can sometimes lead to splenic dysfunction [3], resulting in an increased risk for severe infection, particularly with encapsulated bacteria, malaria and tick-borne parasites.
• Travellers with coeliac disease, irritable bowel syndrome, food intolerances (including gluten and lactose intolerance) and food allergies may face worsening symptoms if specific dietary requirements are not available during travel. Food labelling laws may vary around the world, and additional checks may be required when specific foods or allergens need to be avoided.
• Travellers taking medications used to reduce acid production in the stomach (proton pump inhibitors (PPIs)) should be aware this may lead to increased risk of GI infection.

Health professionals are encouraged to discuss with the travellers' specialist if there is any concern about an underlying medical condition or treatment.

Pre-travel preparation

Advice for those with gastrointestinal disorders should follow that given to all travellers, and tailored to the individual, considering their underlying medical condition, severity of illness and current and past treatments. Assessment of a travellers' risk and suitability of their destination and plans should ideally be discussed with a healthcare professional (and / or specialist for some conditions) prior to booking.

Destination specific risks and how to reduce risks can be found on the Country Information pages. Medical facilities at the destination should also be considered, together with access to care. Specific societies for some GI disorders exist and can also offer information and support (see Resources).

Those with relapsing/remitting GI disorders e.g. Crohn's disease and ulcerative colitis should ideally travel when well, and not during a flare-up of their condition. Relapse or exacerbation of an underlying condition due to infection, change in diet, decreased compliance or lack of availability of IBD medication are all potential risks associated with travel for those with IBD [4].

Travellers should plan how they would manage an emergency overseas, such as a flare-up of their condition, loss of equipment or medications. Occurrence of IBD flare-ups during international travel were found to be greater in those with additional health issues [5]. For travellers with IBD, a written plan of action from the travellers' IBD team, to be used in the event of a flare whilst travelling may be useful.

An online travel resource for inflammatory bowel disease - the IBD Passport - contains information and advice for travellers, an interactive map and directory of IBD centres globally, together with information on how to access healthcare systems in individual countries.

Concern over access to (clean) toilet facilities, quality of medical care and availability of suitable food have been cited as barriers to overseas travel for those with IBD [6].

The 'Can't Wait Card' is a discreet way of communicating the need for help to members of staff in shops and in public places, to enable quicker access to toilets. The card is available in different languages from a number of organisations.

IBD patients can be immunocompromised through their IBD treatment. Travellers with IBD may be taking immunosuppressants or immunomodulators such as corticosteroids, methotrexate and/or biological therapies e.g. tumour necrosis factor inhibitors. Depending on the medication, dose and other health issues including older age, this may increase the risk of infection and severe disease [2]. Further information on pre-travel preparation and resources for immunosuppressed travellers can be found here.

Around 30% of adults with coeliac disease have splenic dysfunction [3]. Assessment of splenic function will be needed on an individual basis. Advice on the need for additional immunisations and antibiotic prophylaxis and standby treatment is available [7]. Those with no spleen or severely impaired splenic function are at particular risk of severe malaria, and where possible, travel to malarious areas should be avoided [7, 8].

Adequate medication should be taken for the duration of the trip. Substandard or falsified medication can be a problem in some countries. Consider the need for emergency self-treatment in the event of worsening disease if medical facilities are not readily available [4]. For those with IBD who are receiving regular intravenous medications, arrangements for administration will need to be made, in consultation with their specialist team.

Regulations on importing or transporting medicines to the destination country need to be checked. Carrying a letter from a specialist or GP with diagnosis and current drug treatment is advisable; this is particularly important if carrying medications or equipment (including needles and syringes) which need to be declared to the airline. Medicines that are normally stored in the fridge and which need to be kept cool during travel may be transported in a cool bag or cooling wallet. All medications should be carried in hand luggage as luggage may be lost - see the Medicines and travel factsheet and IBD passport for further information.

Some long-haul flights may cross different time zones and disrupt usual routines. This will require travellers to manage their medication regimens, which can be discussed with the individual's specialist team.

A very small number of medicines prescribed in the UK may contain wheat starch, which contain low levels of gluten. Labels and patient information leaflets should be checked; in most cases, an alternative medicine can be prescribed which does not contain wheat starch. Coeliac UK has produced Travel Guides for a number of countries with information on labelling laws and contact details for local coeliac societies.

Comprehensive travel insurance is essential for all travellers. A full declaration of medical conditions should be made to the insurers and all equipment and planned activities should be covered. Individual societies supporting those with gastrointestinal disorders may provide a list of insurance companies that provide cover for specific disorders.

Residents of the UK can apply for a UK Global Health Insurance Card (GHIC), which gives travellers the right to access state-provided healthcare during a temporary stay in the European Union (EU). The GHIC card is not an alternative to travel insurance, and does not cover costs such as mountain rescue, or being flown back to the UK. Travel insurance is therefore advised for all travel.

Journey risks

Those travelling with a GI disorder may have specific dietary requirements. Where food is included on a flight, any specific dietary needs should be arranged with the airline in advance.

Following any recent surgery, specialist advice may be needed about timing of air travel. If abdominal surgery has recently been necessary, air travel should be avoided for 10 days, as intestinal gas will expand during an air flight and increase the risk of post-operative complications such as tearing sutures, bleeding or in extreme circumstances perforations. Following other procedures, such as colonoscopy, where a large amount of gas has been introduced into the colon, air travel should be avoided for 24 hours. Similarly, it is advisable to avoid flying for approximately 24 hours after laparoscopic (keyhole) intervention, due to the residual gas, which may be in the intra-abdominal cavity [9]. Guidelines are available from The International Air Transport Association (IATA).

Venous thromboembolism

Venous thromboembolism (VTE: deep vein thrombosis or pulmonary embolism) can occur as a result of long periods of immobility associated with any form of travel. Measures to prevent travel related VTE including maintaining mobility in-flight are advised [10]. Additional information on reducing the risk of VTE can be found on the Venous thromboembolism factsheet.

Food and water-borne risks

Gastrointestinal infection acquired during travel can cause worsening or recurrence of a pre-existing GI disorder. Travellers should be encouraged to seek early medical care in the event of illness or worsening of certain underlying gastro-intestinal illnesses e.g. IBD.

Care with food hygiene and careful food choices are essential for this group of travellers.

Food and drink known to aggravate any pre-existing GI disorder should be avoided. Those with a known allergy or intolerance should consider whether to take adequate supplies of their own food with them, since specific dietary products and supplements may not be available overseas.

Travellers' diarrhoea (TD) is the most common health problem experienced by travellers. It may be difficult to distinguish between a flare up of IBD and TD, as the symptoms may be similar. Travellers with IBD should seek early medical care in the event of diarrhoeal illness to ensure appropriate management.

After careful risk assessment, standby antibiotics may sometimes be considered when travelling to high-risk countries [11]. Further information can be found in the Travellers' diarrhoea factsheet.

Travellers being treated with immunomodulators are at increased risk of severe illness caused by a number of food and water-borne infections such as Salmonella sp, Cryptosporidium parvum, Shigella, Campylobacter and Giardia [2, 12]. Listeria monocytogenes is also a risk, with a higher incidence in those treated with anti-TNF therapy compared to other immunomodulators [2].

Travellers taking proton pump inhibitors (PPIs) may be at increased risk of infections with acid-sensitive organisms such as Salmonella and Camplyobacter due to reduced acidity in the stomach [12].

Vector-borne risks

Malaria

For those travelling to malaria endemic areas, the ABCD of malaria prevention should be discussed: Awareness of risk of malaria in the area they are travelling; practice good Bite prevention, as this is the first defence against malaria; use of appropriate Chemoprophylaxis; and recognise the importance of responding quickly to potential signs and symptoms of malaria to ensure prompt Diagnosis [8].

Travellers who are immunocompromised are at increased risk of severe malaria if infected [8, 13]. In low-risk areas where antimalarials are not routinely recommended, they may be considered in exceptional circumstances in this group of travellers.

Those with a poorly functioning spleen should be dissuaded from travel to any area with a risk of malaria; but where travel is essential, awareness, rigorous bite avoidance and antimalarials should be advised, even in low-risk malaria areas where bite avoidance and awareness only are recommended for other travellers [8]. For areas regarded as 'very low' malaria risk, antimalarials would not be advised, but bite avoidance and awareness of risk would still apply [8].

Travellers with IBD (who are not immunocompromised due to their medication) do not appear to be at higher risk for acquiring malaria, or for more severe complications of malaria compared to travellers without IBD [2].

Travellers should be aware that all currently recommended drugs for malaria chemoprophylaxis used in the UK (mefloquine, atovaquone/proguanil, doxycycline, and chloroquine) are associated, to different degrees, with gastrointestinal side effects.

Absorption of antimalarial medication may be compromised in those who have had parts of the gut removed due to surgical procedures. It will be necessary to consider where a particular drug is absorbed, and whether absorption is affected by acid or alkaline conditions, food etc. In these instances, specialist advice should be sought.

Potential interactions between antimalarial medication and current drug treatment needs to be considered.

Other vector-borne diseases

For travellers who are immunocompromised, further information on the risk of other vector-borne diseases is available.

Vaccination

Those with gastrointestinal disorders should be up to date with routine immunisations and boosters as recommended in the UK.

As in all travel consultations it is important to consider the underlying medical condition, current health, treatment or drug therapy which may contraindicate the use of vaccines or consider caution in their use:

• Additional vaccines are recommended for individuals considered to be immunosuppressed (e.g. influenza and pneumococcal) [3]. Those who are severely immunocompromised should not be given live vaccines. Where there is doubt about an individual's immune status, specialist advice should be sought.
• Additional immunisations for those with splenic dysfunction need to be considered (e.g. pneumococcal, Meningitis ACWY, Meningitis B, influenza) [3, 7]. For additional information on Haemophilus influenza type b (Hib) in travellers with splenic dysfunction, see our Asplenia and hyposplenia factsheet.
• Individuals with a weakened immune system, and those with conditions leading to splenic dysfunction (e.g. coeliac disease), are considered clinically vulnerable to COVID-19 and have been included in the groups to continue to receive COVID-19 vaccination in the UK (see Tables 2 and 3 in Chapter 14a, COVID-19 in Immunisation against Infectious Disease). Further specific advice for those with IBD is provided by the Crohn's and Colitis UK.
• There is no evidence that vaccination in IBD patients induces a flare [2].
• Autoimmune conditions alone are not considered a contraindication to yellow fever vaccine at this time [14]. There are rare cases of serious adverse events following yellow fever vaccine reported in individuals with autoimmune conditions, including ulcerative colitis and Crohn's disease. However, other risk factors in these cases may have been relevant [15, 16].
• Oral cholera vaccines (Dukoral and Vaxchora) and oral typhoid vaccine should be avoided in those with acute gastrointestinal illness [17-19].
• Inactivated typhoid vaccine is preferred in those with IBD who have had a colectomy [4].
• Vaccine constituents need to be examined carefully to identify components to which an individual may be hypersensitive (e.g. egg proteins, lactose, sucrose).

Health professionals are encouraged to seek expert advice if further information is needed regarding use of vaccines.

General advice for those who become unwell overseas

Travellers should know when and how to seek prompt medical advice. When accessing health care abroad, travellers should inform health professionals of any medical condition they may have, explaining all treatment and medication, along with other relevant background information.

Resources

• NHS Health A-Z
• GutsUK
• Crohn's and Colitis UK
• IBD UK
• IBD Passport: One-stop travel advice for inflammatory bowel disease
• Canadian Society of Intestinal Research: Tips for travelling with IBD
• The IBS Network
• Coeliac UK
• British Society of Gastroenterology consensus guidelines on the management of Inflammatory Bowel Disease (IBD) in adults
• British Society of Gastroenterology guidelines on the management of irritable bowel syndrome