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# Tropical sprue

Tropical sprue is long-lasting diarrhoea and poor absorption of food in people living in or visiting the tropics. It responds to folic acid and antibiotics.

Updated 2026-11-01

## Structures involved

Tap one to see what it is and open it in 3D.

- [Jejunum](https://durgical.com/en/anatomy/jejunum/)
- [Ileum](https://durgical.com/en/anatomy/ileum/)
- [Duodenum](https://durgical.com/en/anatomy/duodenum/)

## Why it happens

- [Patterns of malabsorption](https://durgical.com/en/physiology/patterns-of-malabsorption/)
- [Fat digestion and absorption](https://durgical.com/en/physiology/fat-digestion-and-absorption/)
- [Folate (vitamin B9)](https://durgical.com/en/biochemistry/molecules/folate/)
- [Cobalamin (vitamin B12)](https://durgical.com/en/biochemistry/topics/cobalamin/)
- [Small intestine: villi, crypts, enterocytes, Paneth cells; duodenum vs jejunum vs ileum](https://durgical.com/en/histology/small-intestine-villi-crypts-enterocytes-paneth-cells-duodenum-vs-jejunum-vs-ile/)

## What it is

An acquired malabsorption syndrome of the small intestine that affects residents of, or long-stay visitors to, tropical areas, with chronic diarrhoea, weight loss and deficiencies of folate and vitamin B12, once other causes of malabsorption have been excluded.

## Who gets it

Described mainly in the Caribbean, India and Southeast Asia, and in parts of South America including northern areas close to Colombia; it can appear in travellers and military personnel after months in the tropics. It has become less frequent as sanitation improves, and in Colombia it is a diagnosis of exclusion beside parasitic infections and coeliac disease. Symptoms may begin even years after leaving the tropics.

## Causes

- Cause not fully known; an infectious origin is strongly suspected because of outbreaks and the response to antibiotics
- Persistent colonisation of the small bowel by enteric bacteria (overgrowth) after acute gastroenteritis
- Folate deficiency, which further damages enterocytes and perpetuates the disease
- Environmental and dietary factors

## Risk factors

- Living in or long-term stay (more than a few months) in tropical regions
- Episode of acute infectious diarrhoea while in the tropics
- Poor sanitation and contaminated water
- Pre-existing poor nutrition

## Pathophysiology

An enteric infection or bacterial overgrowth damages the mucosa of the [jejunum](https://durgical.com/en/anatomy/jejunum/) and [ileum](https://durgical.com/en/anatomy/ileum/), producing partial villous blunting, crypt elongation and inflammation along the whole small bowel. Absorptive surface and brush-border enzymes are lost, so fat, D-xylose, folate (jejunum) and vitamin B12 (ileum) are poorly absorbed. Folate deficiency then slows renewal of enterocytes, creating a vicious circle and megaloblastic anaemia.

## Classification

- Acute: begins with an acute diarrhoeal illness, common in visitors
- Chronic: months to years of malabsorption, more typical of residents, often presenting with megaloblastic anaemia

## Symptoms and signs

- Chronic diarrhoea, often fatty and worse with fatty food (steatorrhoea)
- Abdominal cramps, bloating and flatulence
- Weight loss and fatigue
- Sore red [tongue](https://durgical.com/en/anatomy/tongue/) (glossitis) and angular cheilitis
- Pallor from anaemia
- Leg oedema from low protein
- Numbness or tingling from vitamin B12 deficiency in long-standing disease

## Red flags

- Severe dehydration or electrolyte disturbance from diarrhoea
- Marked anaemia with breathlessness or heart failure
- Neurological signs of B12 deficiency (ataxia, loss of proprioception)
- Growth failure in children
- Fever or blood in the stool, which point to another infection or inflammatory bowel disease

## Diagnosis

**Clinical**
Suspected in chronic diarrhoea with malabsorption in someone who lives in or spent a long time in the tropics; it is a diagnosis of exclusion after infections, coeliac disease and other causes are ruled out.

**Tests**
Complete blood count (macrocytic megaloblastic anaemia), low folate and B12, low iron, albumin and vitamin D; stool fat and an abnormal D-xylose test confirm malabsorption; stool tests for parasites (especially Giardia) and coeliac serology to exclude other causes. Duodenal or jejunal biopsy at endoscopy shows partial villous atrophy with inflammation, less severe than in coeliac disease.

**Imaging**
Small-bowel barium study may show thickened folds and dilated loops; mainly used to exclude other diseases.

## Differential diagnosis

- Coeliac disease
- Giardiasis and other intestinal parasites (Strongyloides, Cryptosporidium, Cystoisospora)
- Small intestinal bacterial overgrowth
- Whipple disease
- Crohn disease
- HIV enteropathy
- Environmental (tropical) enteropathy, which is usually subclinical

## Goal of treatment

Restore hydration and nutrition, correct folate and B12 deficiency, and clear the intestinal infection so that the mucosa can heal.

## Treatment

**Acute**
Fluid and electrolyte replacement in patients who are dehydrated.

**Medical**
Folic acid replacement, which quickly improves the anaemia, appetite and the bowel lining; vitamin B12 and iron as needed.

**Medical**
A prolonged course of oral tetracycline (lasting months) or trimethoprim-sulfamethoxazole; tetracyclines are avoided in young children and pregnancy because they stain developing teeth.

**Follow-up**
Follow-up of weight, diarrhoea, blood count and vitamin levels; nursing care includes fluid balance, daily weight and [skin](https://durgical.com/en/anatomy/skin/) care.

## Complications

- Megaloblastic anaemia from folate and B12 deficiency
- Neuropathy from B12 deficiency
- Severe malnutrition and hypoalbuminaemia
- Delayed growth and bone maturation in children
- Deficiency of fat-soluble vitamins (bone loss, bleeding tendency)

## Prognosis

Good with treatment: most patients recover over months with folate and antibiotics. Relapse is possible, especially if the person stays in or returns to the tropics.

## Prevention

- Safe drinking water and food hygiene in tropical areas
- Early evaluation of persistent diarrhoea after travel or residence in the tropics

## Test yourself

Think of the answer, then tap the question to see it.

## What two treatments are the basis of therapy for tropical sprue?

Folic acid replacement and a prolonged course of an antibiotic, classically tetracycline.

## What type of anaemia is typical of tropical sprue?

Megaloblastic (macrocytic) anaemia from folate and vitamin B12 deficiency.

## How does tropical sprue differ from coeliac disease in its distribution and response?

It affects the whole small bowel including the ileum and responds to antibiotics and folate, not to a gluten-free diet.

## Which parasitic infection must be excluded first in tropical malabsorption?

Giardiasis, by stool testing; other parasites such as Strongyloides should also be excluded.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/conditions/tropical-sprue/)

## Related conditions

- [Coeliac disease](https://durgical.com/en/conditions/coeliac-disease/)
- [Giardiasis](https://durgical.com/en/conditions/giardiasis/)
- [Small intestinal bacterial overgrowth (SIBO)](https://durgical.com/en/conditions/small-intestinal-bacterial-overgrowth/)
- [Whipple disease](https://durgical.com/en/conditions/whipple-disease/)
- [Megaloblastic anaemia (B12 or folate deficiency)](https://durgical.com/en/conditions/megaloblastic-anaemia/)
- [Crohn disease](https://durgical.com/en/conditions/crohn-disease/)
- [Lactose intolerance](https://durgical.com/en/conditions/lactose-intolerance/)
- [Strongyloidiasis](https://durgical.com/en/conditions/strongyloidiasis/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Tropical sprue](https://medlineplus.gov/ency/article/000275.htm) (MedlinePlus Medical Encyclopedia (U.S. National Library of Medicine), 2025); [Tropical Sprue](https://rarediseases.org/rare-diseases/tropical-sprue/) (National Organization for Rare Disorders (NORD), 2009).

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Source: https://durgical.com/en/conditions/tropical-sprue/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/tropical-sprue/