Ramadan fasting and digestive disorders: SEPAHAN systematic review No. 7

Abstract

BACKGROUND: During Ramadan, the 9th month in the Hijri lunar calendar, healthy adult Muslims are obliged to fast from sunrise to sunset. The fast of Ramadan has significant health effects and is the most commonly researched religious fasting. In this study, we will investigate available findings on the effects of Ramadan fasting on gastrointestinal (GI) signs, symptoms, and diseases. METHODS: We searched PubMed, Google Scholar, Iran Medex, and Scientific Information Database (SID) for related articles in English or Farsi. Editorial articles and case reports were excluded. RESULTS: Of 2312 articles found, 23 articles fulfilled our inclusion criteria and were included. Ramadan fasting seems to increase peptic ulcer complications (peptic ulcer perforation and bleeding) and have a deteriorating effect on patients with chronic peptic ulcer diseases on drug therapy, but not on duodenal ulcer patients under treatment. Healthy individuals might experience minor GI symptoms but no serious complications have been reported. Studies regarding the incidence of acute appendicitis and peptic ulcer diseases are not in agreement, but acute mesenteric ischemia, hyperemesis gravidarum and primary small bowel volvulus seem to be increased during Ramadan. No increase in idiopathic intussusception is observed during Ramadan and fasting does not appear to impose serious risks on patients with an inflammatory bowel. CONCLUSIONS: Fasting is generally safe for healthy individuals, but might be hazardous to patients with various GI diseases and may increase the risk of complications in this group.

Full text

Review article

S150 Journal of Research in Medical Sciences | March 2012 Special Issue (1) |
Ramadan fasting and digestive disorders:
SEPAHAN systematic review No. 7
Shirin Sadeghpour1, Ammar Hassanzadeh Keshteli2, Parnaz Daneshpajouhnejad1,
Pegah Jahangiri1, Peyman Adibi2
1 Medical Students Research Center, Isfahan University of Medical Sciences, Isfahan, Iran. 2 Integrative Functional Gastroenter-
ology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
BACKGROUND: During Ramadan, the 9th month in the Hijri lunar calendar, healthy adult Muslims are obliged to fast from sunrise
to sunset. The fast of Ramadan has significant health effects and is the most commonly researched religious fasting. In this study, we
will investigate available findings on the effects of Ramadan fasting on gastrointestinal (GI) signs, symptoms, and diseases.
METHODS: We searched PubMed, Google Scholar, Iran Medex, and Scientific Information Database (SID) for related articles in
English or Farsi. Editorial articles and case reports were excluded. RESULTS: Of 2312 articles found, 23 articles fulfilled our inclu-
sion criteria and were included. Ramadan fasting seems to increase peptic ulcer complications (peptic ulcer perforation and bleeding)
and have a deteriorating effect on patients with chronic peptic ulcer diseases on drug therapy, but not on duodenal ulcer patients un-
der treatment. Healthy individuals might experience minor GI symptoms but no serious complications have been reported. Studies
regarding the incidence of acute appendicitis and peptic ulcer diseases are not in agreement, but acute mesenteric ischemia, hyper-
emesis gravidarum and primary small bowel volvulus seem to be increased during Ramadan. No increase in idiopathic intussuscep-
tion is observed during Ramadan and fasting does not appear to impose serious risks on patients with an inflammatory bowel.
CONCLUSIONS: Fasting is generally safe for healthy individuals, but might be hazardous to patients with various GI diseases and
may increase the risk of complications in this group.
KEYWORDS: Ramadan Fasting, Islamic Fasting, Gastrointestinal Diseases, Gastrointestinal Signs and Symptoms.
BACKGROUND
With1∙57billionfollowersworldwide,Islamisthe
world’ssecondlargestreligion.[1]DuringRamadan,
whichisthe9thmonthoftheIslamiclunarcalendar,
alladultMuslimsareobligedtofast;i.e.refrain
fromeating,drinking,smokingandengagingin
sexualactivitiesfromsunrisetosunset.[2]

Ramadanlasts29to30dayseachyear.Sincethe
Islamiccalendar(theHijricalendar)isalunarca‐
lendar,thefirstdayofRamadanadvances11to12
dayseachyearcomparedtotheGregoriancalendar.
HenceRamadanoccursindifferenttimesofthe
seasonalyearovera33‐yearcycle.[2,3]

DependingontheseasonRamadanfallsin,and
alsothelatitude,thedurationofthefastvariesbe‐
tween11and18hoursinthenorthandintropical
countries.[4]

AlladultMuslimsarerequiredtofastwiththe
exemptionofthesick,thetravelersandmenstruat‐
ing,pregnantorlactatingwomen;however,many
oftheindividuals,whocouldbeconsideredex‐
empt,decidetofast.[2,4]

DuringthemonthofRamadan,eatingpatterns
change.Individualsconsumetworelativelylarge
meals,onebeforethedawn(Sahur)andtheother
rightafterthesunset(Iftar).Thefoodconsumed
duringRamadanisusuallyrichandhighinprotein
andfat.[5,6]Thealterationincircadianrhythmisalso
ofsignificance:theindividualsbecomemoreactive
aftersunsetandinthenightandtheymayalsobe‐
comesleepdeprived.[2,7]

ThemonthofRamadanisareligiousfestival
andfastingismainlyaritualforMuslims topractice
self‐controlandself‐discipline,andempathizewith
theimpoverished.Moreover,fastingduringRama‐
danhassignificanthealtheffectsandisthemost
commonlyresearchedreligiousfasting.[8]

Inthepasttwodecades,studieshavebeencon‐
ductedtoevaluatetheimpactoffastinginRama‐
danonthegastrointestinal(GI)tract.Nonetheless,
thefindingshavebeenheterogeneous,andthere‐
fore,noconsensusexistsregardinghowGItract
mightbeaffectedbythefastinginRamadan.

Inaretrospectivestudyovera10yearperiod,
Beneretal.didnotfindanincreaseinthefrequency
ofpepticulcerdiseaseduringRamadan.[9]Moreo‐
ver,Tavakkolietal.foundnocorrelationbetween
Address for correspondence: Ammar Hassanzadeh Keshteli, Integrative Functional Gastroenterology Research Center, Isfahan University of Medical
Sciences, Isfahan, Iran. E-mail: hasanzadeh@med.mui.ac.ir
Received: 01-03-2012; Revised: 25-03-2012; Accepted: 30-03-2012
www.mui.ac.ir

Sadeghpour, et al.: Ramadan fasting and digestive disorders
| March 2012 Special Issue (1) | Journal of Research in Medical Sciences S151
Ramadanfastingandtheseverityofinflammatory
boweldiseases(IBD)inthepatients.[10]

Otherstudieshoweversuggestthatpepticulcer
perforationissignificantlyincreasedduringthefasting
ofRamadan.[2,11]

Furthermore,Ozkanetal.foundthatsignificantly
morepatientswerediagnosedwithacuteupperGI
hemorrhageduringRamadancomparedwithanon‐
Ramadanmonthandsuggestedthatfastingduring
Ramadan“reactivatesandaggravatestheseverityand
complicationsofpre‐existingGIdiseaseslikepeptic
ulcerandgastritis”.[12]Anotherstudycametothecon‐
clusionthatRamadanfastingcanincreaseacuteupper
GIbleeding,butfastingpatientsdonothaveapoorer
prognosisthannon‐fastingpatients.[13]

Toourknowledge,thereisnoreviewarticleonthe
impactofRamadanonGItracttodate.Theaimofthis
paperistosystematicallyreviewthepublishedlitera‐
tureregardingthe effectofRamadanontheGItract.

METHODS

Literaturesearch
Datawereobtainedbyasearchofthepublishedlitera‐
turecitedinPubMed,GoogleScholar,ScientificInfor‐
mationDatabase(SID)andIranMedex.Searchofall
databasesfrominceptiontopresentwasperformed
andthelastsearchwasconductedonMarch11,2012.

AsearchofPubMedwascarriedout.PubMed
querywas:((((Ramadan)ANDʺSignsandSymptoms,
Digestiveʺ[Mesh])ORRamadan[Title])ORIslamic
fasting)ORRamadhan.Theterm“Ramadhan”isaless
frequentlyusedvariantof“Ramadan”.

GoogleScholarwassearchedforarticleswiththe
terms“Ramadan”and“Islamicfasting”intheirtitle.
Onlyarticlesinthefollowingsubjectareaswere
searched:medicine,pharmacologyandveterinary
sciences(thelimitationwaschosenfrom“articlesand
patents”,inadvancedscholarsearch).Articleswith
equivalentFarsitermsintheirtitleswerealsosearched
inallsubjectareas.

Likewise,thedatabasesIranMedex(www.iran‐
medex.com)andSID(www.sid.ir)weresearchedfor
articlesincluding“Ramadan”and”Islamicfasting”
andtheirequivalenttermsinFarsi,inallfields.The
aimwastoespeciallyidentifyarticlesinFarsiandar‐
ticlesinlocaljournals.
Referencelistsfrompotentiallyrelevantarticles
werealsohandsearchedtoidentifyanyadditional
studiesthatmayhavebeenmissedusingthecomput‐
er‐assistedsearchstrategy.

Studyselectioncriteria
Twoinvestigatorsreviewedthetitlesandabstractsof
allcitationsidentifiedbytheliteraturesearch.Full
textsofthepotentiallyrelevantstudieswereretrieved
andtheselectioncriteriawereapplied.Theselection
criteriawere:(1)datapresentingarticlesofstudies
comparingGIsigns,symptomsanddiseasesbefore
and/orduringRamadanwiththoseofafterRamadan,
orcomparingGIsigns,symptomsanddiseasesbe‐
tweenfastingandnon‐fastingsubjects;(2)publishedin
fullmanuscript;and(3)inEnglishorFarsionly.Edi‐
torialarticlesandcasereportswereexcluded.

Dataextraction
Eligiblearticleswerereviewedbytworeviewers,and
datawereextracted.Fromeacheligiblearticle,data
wereextractedonfirstauthor,yearofpublication,title,
journal,studypopulation,samplesize,mainstudy
outcomeandfindings,studydesignandmethods,and
thedemographicfactorstakenintoconsiderationin
thestudy.Theextracteddatawerethenenteredintoa
table.Asummaryofthattableispresentedinthisar‐
ticle(Table1).

RESULTS

Withtheabovedescribedsearches,476articleswere
foundsearchingPubMed.SearchofGoogleScholar
identified1322articlesandsearchofIranMedexand
SIDdatabasesledtoidentificationof363and151ar‐
ticles,respectively.Reviewingthetitlesandabstracts,
followedbythereviewofthefullmanuscriptsofpoten‐
tiallyrelevantarticles,identified23articlesthatmetour
inclusioncriteria(Figure1).Characteristicsandfindings
oftheselectedarticlesaresummarizedintable1.











Figure 1. Diagram of the searches for the systematic review of
the gastrointestinal effects of Ramadan fasting
Withabstractreview,27articleswerefoundtoberelevant
23articleswereidentifiedtomeetourinclusioncriteria
withfulltextreview
Afterscreeningthetitles,36articleswereselected
Searchinelectronicdatabasesyielded2312articles
www.mui.ac.ir

Sadeghpour, et al.: Ramadan fasting and digestive disorders
S152 Journal of Research in Medical Sciences | March 2012 Special Issue (1) |
Table 1: Relationship between Ramadan fasting and gastrointestinal disorders based on previous publications
Row # First au-
thor Design (case-
control, co-
hort, RCT,)
# of observa-
tions (partici-
pants under
analysis)
Setting (population or
geographic location) Main expo-
sure(s) or
variable un-
der study
Main out-
come(s) Magnitude of effect(s) or brief of findings Explanations (e.g. if the study was
only on women, or only on a specific
age group, etc.)
1 Al-Kaabi
S. [22] Cross sectional 516 Patients with PUD Ramadan PUD No increase was found in PUD incidence during Rama-
dan compared to periods before and after Ramadan.
More patients had DU in Ramadan compared to the
period before Ramadan (55% vs. 39.3%, p < 0.05).
The study period included almost 3
months, the month of Ramadan and a
period of time before and after it.
2 Bener A.
[9] Cross sectional 470 Patients treated for PUD Ramadan PUD and
PPU Frequency of PUD and PPU was higher in the month
after Ramadan compared to that of Ramadan (p >0.05
and p = 0.008 respectively).
Patients treated in Ramadan and the
month after, during a 10-year period
3 Chong
VH. [23] Cross sectional 1661 Patients referred for upper
GI endoscopy to a referral
centre
Ramadan
Upper GI
endoscopy
referrals and
findings
There was less workload for the endoscopy centre
during Ramadan. Number of the patients referred to
the centre: BR: 603, R: 397, AR: 661 (p < 0.05)
More patients with GI bleeding were referred during
Ramadan. Percentage of patients referred with the
indication of GI bleeding to the total number of patients
referred: BR: 10.9%, R: 16.6%, AR: 13.5% (p = 0.153)
There was no significant difference in endoscopic find-
ings in the esophagus and stomach.
More duodenal ulcer diseases were encountered dur-
ing and after Ramadan. Percentage of patients with
duodenal ulcer disease in the total number of patients
referred: BR: 7.5%, R: 14.1%, AR: 12.6% (p = 0.001)
Patients referred a month before, dur-
ing, and a month after Ramadan over a
4-year period
4 Darvish
Mogha-
dam S. [21]
Cohort 125 Healthy fasting volunteers Fasting GI symptoms GI symptoms (nausea, vomiting, diarrhea, constipation,
etc.) occurred in 58.4% of volunteers. However, symp-
toms were mild and none of the volunteers stopped
fasting due to severity of GI symptoms.
Women had 1.7 times more GI symptoms than men (p
< 0.02).
All participating individuals fasted for
more than 21 days.
5 Davouda-
badi A. [14] Cross sectional 1256 Patients with acute appen-
dicitis (diagnosis confirmed
by pathology report after
surgical excision)
Ramadan Acute ap-
pendicitis Significantly less patients underwent surgery for acute
appendicitis during Ramadan compared to other
months (p < 0.0001) and most patients underwent
surgery for acute appendicitis in the month after Ra-
madan (p < 0.001)
Patients aged from 15 to 70 years,
admitted during 3 consecutive Hijri
years
6 Davooda-
badi A. [15] Cross sectional 1773 Patients with acute appen-
dicitis (diagnosis confirmed
by pathology report after
surgical excision)
Ramadan Acute ap-
pendicitis The incidence of acute appendicitis is significantly
reduced during Ramadan, while it increases sharply in
the month after Ramadan (p < 0.001).
Patients aged from 15 to 70 years,
admitted during 3 consecutive Hijri
years
7 Donderici
O. [25] Cross sectional 1114 Patient hospitalized for
PUC Ramadan PUC PUC increased with Ramadan fasting.
Share of patients with PUC among the total number of
patients hospitalized:
BR: 14.3%, R: 20.5%, AR: 15.4%
(difference between R and BR: p < 0.05
Difference between R and AR: 0.1 > p > 0.05)
Female patients tended to develop more hemorrhage
and perforation during Ramadan than male patients
(0.05 > p > 0.01).
Patients admitted one month before,
during, and one month after Ramadan
during a 6-year period
8 Duke JH
Jr. [28] Cross sectional 26 Patients with primary small
bowel volvulus
Ramadan Primary
small bowel
volvulus
There was a tenfold and ninefold increase in the inci-
dence of primary small bowel volvulusin the two fasting
months (Ramadan) during the study. 73% of cases
presented during Ramadan.
Duration of the study was 13months,
the first and last month was Ramadan.
www.mui.ac.ir

Sadeghpour, et al.: Ramadan fasting and digestive disorders
| March 2012 Special Issue (1)| Journal of Research in Medical Sciences S153
Table 1: Relationship between Ramadan fasting and gastrointestinal disorders based on previous publications (Continue)
Row # First au-
thor Design (case-
control, co-
hort, RCT,)
# of observa-
tions (partici-
pants under
analysis)
Setting (population or
geographic location) Main expo-
sure(s) or
variable un-
der study
Main out-
come(s) Magnitude of effect(s) or brief of findings Explanations (e.g. if the study was
only on women, or only on a specific
age group, etc)
9 Elnagib E.
[24] Cross sectional 58 Patient with PPU
Ramadan PPU
The incidence of PPU increased in Ramadan, 37.9% of
perforations occurred during Ramadan. Patients admitted during a period of two
and a half years.
10 Emami
MH. [13] Cohort 236 Patients admitted to a
hospital with AUGIB Fasting AUGIB
causes;
Dyspeptic
symptoms;
prognosis of
AUGIB
The fasting group had more DU (38% vs. 19.5%), but this
was only significant for 20 to 60-year old patients (p <
0.05). The frequency of esophageal varices was higher in
the non-fasting group (11.7% vs. 3.7%, p < 0.05), which
was significant for patients more than 40 years old.
In the fasting group 38% and in non-fasting group
18.9% had a history of dyspeptic symptoms (p = 0.001,
OR = 2.62).
There was no significant difference between the two
groups in terms of the outcome of AUGIB and progno-
sis, but mortality was higher in the fasting than the non-
fasting group (12.5% vs. 3.7%, p = 0.016).
Patients admitted from the 10th day of
Ramadan until one month after during a
2-year period. Fasting group consisted
of patients who were fasting at least
10days before admission.
11 Gocmen
E. [3] Cross sectional 1408 Patients admitted to sur-
gical emergency unit Ramadan PPU;
Acute me-
senteric
ischemia
PPU nearly doubled during Ramadan compared to the
months before and after (BR: 7.7%; 95%CI 1.05-1.10, R:
16.0%; 95%CI 1.12-1.19, AR: 7.9%; 95%CI 1.05-1.10).
There was a more than twice increased ratio of acute
mesenteric ischemia during Ramadan (BR: 1.6%;
95%CI 1.00-1.02, R:3.7%; 95%CI 1.02-1.05, AR: 1.4%;
95%CI 1.00-1.02)
Patients admitted one month before,
during and one month after Ramadan
during a 4-year period.
12 Hosseini-
Asl K. [19] Cohort 39 Patients with endoscopi-
cally proven DU
Fasting Treatment of
DU Fasting did not have a deteriorating effect on healing of
duodenal ulcer and patients with active duodenal ulcer
could fast, receiving the treatment employed in the
study. A 94.4% cure in the fasting group and a 95.5%
cure in the non-fasting group was detected
.
All patients were receiving Omeprazole
as a treatment.
13 Jastaniah
S. [27] Cross sectional 27 Patients with perforated
duodenal ulcer Ramadan Duodenal
ulcer perfo-
ration
There was no increase in the prevalence of perforation
of duodenal ulcer during Ramadan. Patients admitted during a 7-year pe-
riod.
14 Kucuk HF.
[26] Cross sectional 260 Patients undergoing urgent
operation for perforated
duodenal ulcer
Ramadan Duodenal
ulcer perfo-
ration
The incidence of duodenal ulcer perforation was higher
in Ramadan. The number of patients undergoing sur-
gery per Ramadan was 10 while that of non-Ramadan
months was 3.8 (p < 0.018).
History of dyspepsia significantly increased the risk of
perforation in fasting people in Ramadan compared
to the non-Ramadan group (p < 0.05)
.
within a 5-year period
15 Kuruvilla
MJ. [30] Cross sectional 114 Patients with intestinal
obstruction Ramadan Intestinal
obstruction There were no cases of idiopathic intussusception
during or immediately following Ramadan. Duration of the study was 30 months.
16 Malik GM.
[18] Cohort 38 Patients with endoscopi-
cally proven PUD
Fasting Treatment of
PUD Chronic PUD was difficult to cure during Ramadan fast-
ing and fasting might be hazardous to patients with PUD.
The non-fasting group showed no change after Rama-
dan. All fasting patients with ADU healed. 7 of 8 pa-
tients with active CDU bled during Ramadan. 7 of 8
patients with HDU showed no change, one developed
a new active ulcer. One patient had a CGU, he bled
during Ramadan.
All patients were receiving an H2
blocker drug as a treatment.
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Sadeghpour, et al.: Ramadan fasting and digestive disorders
S154 Journal of Research in Medical Sciences | March 2012 Special Issue (1) |
Table 1: Relationship between Ramadan fasting and gastrointestinal disorders based on previous publications (Continue)
Row # First au-
thor Design (case-
control, co-
hort, RCT,)
# of observa-
tions (partici-
pants under
analysis)
Setting (population or
geographic location) Main expo-
sure(s) or
variable un-
der study
Main out-
come(s) Magnitude of effect(s) or brief of findings Explanations (e.g. if the study was
only on women, or only on a specific
age group, etc)
17 Mallk GM.
[17] Cohort 80 Patients with endoscopi-
cally proven PUD
Fasting Treatment of
PUD Chronic PUD was difficult to cure during Ramadan
fasting and fasting might be hazardous to patients with
PUD.
All patients with ADU (4 of 4) showed signs of healing. In
the group of patients with CDU (16 patients), 62.5% (10
patients) bled during the study, while others showed no
change on the repeat endoscopy. In patients with HDU
(20 patients), 85% (17 patients) showed no change, but
the others developed new ADU. One patient had CGU
and bled during the fasting period. No changes were
detected after Ramadan in non-fasting patients.
All patients were receiving Ranitidine
as a treatment.
18 Mehrabian
[20] Cohort 84 Patients with DU Fasting Treatment of
DU DU healed in 75.5% of non-fasting and 85.7% of fast-
ing patients (p = 0.05). All patients were receiving Omeprazole
as a treatment.
19 Ozkan S.
[12] Cross sectional 71 Patients presenting with
AUGIB
Ramadan AUGIB The number of patients diagnosed with AUGIB during
Ramadan was higher than that of the non-Ramadan
month (p < 0.05).
Patients aged > 16 admitted during
Ramadan and a non-Ramadan month
(2 months after Ramadan) in one year.
20 Rabiner-
son D. [29] Cross sectional 211 Patients with hyperemesis
gravidarum Ramadan Hyperemesis
gravidarum Hyperemesis gravidarum was more frequent in Rama-
dan.
Patients admitted in Ramadan/The total number of
patients admitted: 76/211 (p < 0.05)
Pregnant Muslim women during the first
trimester admitted during an 11-year
period.
21 Sulu B.
[16] Cross sectional 992 Patients with acute appen-
dicitis (diagnosis confirmed
by pathology report after
surgical excision)
Ramadan Acute ap-
pendicitis
Ramadan did not increase the frequency of acute ap-
pendicitis. Percentage of patients with acute appendici-
tis undergoing surgery:
BR: 37.1%, R: 32.1, AR: 30.8% (p > 0.05)
Patients aged > 10 diagnosed during
Ramadan, the month before and the
month after, over a 4-year period
22 Tavakkoli
H. [10] Cohort 60 Patients with IBD in remis-
sion Ramadan
Fasting Severity of
symptoms of
IBD
Ramadan did not cause aggravation in IBD patients’
symptoms.
Mean score of CAI in UC patients: BR: 2.97±2.33, AR:
1.88±1.67 (p = 0.005)
CAI decreased in UC male patients (BR: 3.5, AR: 1.7;
p = 0.008) but not in UC female patients (BR: 2.5, AR:
2; p = 0.3).
In CD patients, mean score of CDAI was: BR: 102.5,
AR: 92.5 (p = 0.6)
There was no difference in patients’ scores or changes
of scores and type of disease between fasting and non-
fasting patients.
26 patients did not fast, 5 patients
fasted for all 30 days and 29 patients
fasted for 1-29 days
23 Torab FC.
[11] Cross sectional 116 Patients with intraopera-
tively confirmed PPU Ramadan PPU There was a significant increase in the admission of
patients with PPU during Ramadan (p < 0.004) Patients aged > 18 diagnosed over a
period of 4 years and 3 months.

PUD: Peptic ulcer diseaseDU:Duodenal ulcerPPU:Perforated peptic ulcerGI:GastrointestinalBR:Before ramadanR:RamadanAR:After ramadanPUC:Peptic ulcer complications
AUGIB:Acute upper GI bleedingADU:Acute duodenal ucerCDU:Chronic duodenal ulcerHDU:Healed duodenal ulcerCGU:Chronic gastric ulcer IBD:inflammatory bowel disease
CAI:Colitis activity indexUC:Ulcerative colitisCD:Crohn's diseaseCDAI:Crohn's disease activity index
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Sadeghpour, et al.: Ramadan fasting and digestive disorders
| March 2012 Special Issue (1)| Journal of Research in Medical Sciences S155
Acuteappendicitis
Threearticleswerefoundtohaveinvestigatedtheef‐
fectofRamadanontheincidenceofacuteappendici‐
tis.[14‐16]Davoudabadiet.alinvestigatedmedical
recordsofallpatientsadmittedtothehospitalwith
acuteappendicitisandundergoingsurgeryduringa3‐
yearperiod.[14]Thefindingsshowedthattheincidence
ofacuteappendicitiswassignificantlylowerduring
Ramadan,comparedtoothermonths;however,itis
significantlyhighinthemonthafterRamadanandalso
duringMuharram,thefirstmonthofthelunarHijri
calendar.Anotherstudywithaverysimilardesign
wascarriedout,[15]andtheresultswereinaccordance
withthoseofthepreviousstudy.Amorerecentstudy
ontheotherhand,comparedtheincidenceofacute
appendicitisduringRamadan,withthatofthemonth
beforeandafterRamadan.[16]Theincidenceofacute
appendicitisreportedbythisstudywashigherinRa‐
madancomparedtothefollowingHijrimonth,and
hencetheresultsofthisstudydidnotconfirmthoseof
theothertwo.Furthermorethisstudyreportedthat
therewasnosignificantdifferencebetweenRamadan
andthemonthbeforeandafteritintermsoffrequency
ofperforation(p>0.05).

TreatmentofPepticUlcerDiseases
Twocohortstudiesevaluatedtheeffectoffastingon
thetreatmentofpepticulcerdiseases(PUD).[17,18]In
bothstudies,anumberoffastingandnon‐fastingpa‐
tientsreceivedanH2‐blockerdrugduringRamadan
andwereendoscopedbeforeandafterRamadan.Pa‐
tientsinbothfastingandnon‐fastinggroupswould
taketheirdrugsatSahurandIftar.Inbothstudies,the
conditionofpatientsinthefastinggroupimprovedor
worsened,whilenochangewasdetectedinthenon‐
fastinggrouponrepeatedendoscopy.Healingofero‐
siveduodenitis(ED)wasalsoevaluatedinbothstu‐
dies.Inthefirststudy,[17]56.25%offastingpatients
withEDshowednochange,whiletherestshowed
signsofhealing.Inthesecondstudy,[18]fastingpatients
withEDhadcompletelyhealedafterRamadan.Find‐
ingsofthetwostudiesweregenerallyinagreement,
butthenameofthedrugwasnotmentionedinthe
secondstudy.

TreatmentofDuodenalUlcer
Intwocohortstudies,fastingandnon‐fastingpatients
withduodenalulcer(DU)hadbeencomparedinterms
oftheirtreatmentresponsetoOmeprazole.[19,20]Endos‐
copicevaluationwasperformedbeforeandafterRa‐
madan.Inbothstudies,patientsreceived40mgof
Omeprazoleperday.Bothstudiessuggestedthatpa‐
tientswithDUcouldfastwhileonthepreviouslyde‐
scribeddrugregimen.
GIsymptomsinhealthyindividuals
Wefoundonlyonestudyregardingtheeffectoffast‐
ingonGIsymptomsinhealthyindividuals.[21]GI
symptomsoccurredin58.4%oftheparticipants.The
mostprevalentGIsymptomswerebelching,bloating
andfullnesssensation;thethreesymptomshadan
overallprevalenceof19.9%(valueswerenotreported
separately);whiletheleastprevalentGIsymptomwas
diarrheawithaprevalenceof0.6%.OtherGIsymp‐
tomsandtheirprevalencewereasfollows:mouthdry‐
nessandbittertasteinthemouth(18.7%),epigastric
painanddiscomfort(11.7%),earlystarvation(10.5%),
earlysatiety(9.9%),lossofappetite(8.8%),heartburn
(5.3%),abdominalpain,flankpainandperiumbilical
pain(5.3%),constipation(5.3%),nauseaandvomiting
(4%).Fastingpatientsweredividedintotwogroups
withdifferentdiets:onegrouphadalightmeallike
breakfast,andtheotheralargemealforSahur.Respec‐
tively55.2%and59.4%ofindividualsinthefirstand
secondgroupexperiencedGIsymptoms,butthisfind‐
ingwasnotstatisticallysignificant(p>0.4).Moreover,
mostoftheupperGIsymptomswerefoundtocorre‐
latewithsomedietarycomponents.UpperGIsymp‐
tomsincluded:mouthdrynessandbittertasteinthe
mouth,heartburn,epigastricpainanddiscomfort,nau‐
seaandvomiting,earlystarvation,earlysatietyand
lossofappetite.GIsymptomsandcorrelateddietary
componentswereasfollows:mouthdrynessandbitter
tasteinthemouthwithcarbohydrateintake(p<0.04),
nauseaandvomitingwithfatandproteinintake
(p<0.02),earlystarvationandlossofappetitewithall
ofthementioneddietarycomponents.Therewasalsoa
correlationbetweentheoverallupperGIsymptoms
anddietarycomponents(p<0.05).

FrequencyandincidenceofPUD
RegardingthefrequencyofPUD,Al‐Kaabietal.found
noincreaseduringRamadan,[22]andBeneretal.re‐
portedahigherfrequencyofPUDinthemonthafter
Ramadan,comparedtothatofRamadan.[9]Additional‐
ly,Chongetal.reportedthatahigherpercentageof
patientsreferredtoanendoscopycenter,hadduodenal
ulcerduringRamadan,comparedtotheprecedingand
followingmonths(p=0.001).[23]Theyalsoobserved
thatmorepatientswerefoundtohavegastriculcersin
Ramadan,butthedifferencewasnotsignificant
(p=0.09).

FrequencyofPepticUlcerPerforation
Severalstudieswerecarriedouttoevaluatethefre‐
quencyofpepticulcerperforation(PUP)inRamadan.
Mostofthesestudiesshowedthatthefrequencyof
PUPisincreasedduringRamadan,[3,9,11,24]andonlyone
studyhasreportedthatfrequencyofPUPislowerin
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Sadeghpour, et al.: Ramadan fasting and digestive disorders
S156 Journal of Research in Medical Sciences | March 2012 Special Issue (1) |
Ramadan,comparedtothefollowingHijrimonth.[9]
Dondericireportedthatpepticulcercomplicationsare
morefrequentduringRamadancomparedtoperiods
beforeandafter.[25]Pepticulcerperforationandduo‐
denalulcerperforationweresignificantlymorefre‐
quentduringRamadan,comparedtoperiodsbefore
andafterRamadan(p<0.01).

FrequencyofDuodenalUlcerPerforation(DUP)
Ofthreestudies,tworeportedanincrease,[25,26]andone
reportednochange[27]inthefrequencyofDUPinRa‐
madan.

InflammatoryBowelDiseases
Onlyonestudywasfoundevaluatingtheseverityof
symptomsinIBDpatientsbeforeandafterRamadan,
andithadsuggestedthatRamadanfastingdoesnot
imposeseriousrisksonIBDpatients.[10]

AcuteUpperGIBleedingfrequency,causesandprog‐
nosis
Dondericietal.reportedthatamongpatientswith
pepticulcercomplications,theratioofpatientswith
acuteupperGIbleeding(AUGIB)wassignificantly
higherduringRamadancomparedwiththemonths
beforeRamadan(0.05>p>0.01),butthesamediffer‐
enceafterRamadanhadnostatisticalsignificance.[25]

Emamietal.comparedthecausesofAUGIB(DU,
erosivegastritis,gastriculcer,esophagealvarices,Mal‐
lory‐Weiss,obscureAUGIB,andothercauses)infast‐
ingandnon‐fastingpatients,andfoundnocorrelation
betweenfastinganddifferentcausesofAUGIB,except
forDUandesophagealvarices;.[13]DUwasmorefre‐
quentinthefastinggroupandthefrequencyofeso‐
phagealvariceswassignificantlyhigherinthenon‐
fastinggroup.Inthisstudypatientswerealsocom‐
paredintermsoftheoutcomeofAUGIB.Rebleeding
inhospital,needforsurgery,meanvolumeofinfused
packedcell,meannumberofdaysinhospital,and
mortalityrateswerecompared.Bothgroupsweresim‐
ilarandnostatisticallysignificantdifferencewasde‐
tected,exceptformortality:themortalityratewas
higherinthenon‐fastinggroup(12.5%vs.3.7%,
p=0.016).

Anotherstudyshowedthatahighernumberofpa‐
tientswerediagnosedwithAUGIBinRamadancom‐
paredtoanon‐Ramadanmonth.[12]Nostatisticallysig‐
nificantdifferencewasfoundbetweenthetwogroups
regardingtheoutcomeofAUGIB(admissiontogastro‐
enterology,admissiontoCU,discharge,andadmission
togeneralsurgery).Inaddition,thisstudyreporteda
higherfrequencyofDU,esophagealvaricesandgastric
ulcersinAUGIBpatientsduringRamadan(p<0.05).

Otherfindings
Studiesalsoshowedanincreaseinprimarysmallbo‐
welvolvulus,[28]hyperemesisgravidarum,[29]and
acutemesentericischemia,[3]andadecreaseinadmis‐
sionofpatientswithidiopathicintussusception[30]
duringRamadan.

DISCUSSION

Oursystematicreviewdemonstratedthatfastingis
generallysafeforhealthyindividuals,butmightbe
hazardoustopatientswithcertainGIdiseasesand
couldincreasetheriskofcomplicationsinthisgroup.

ThefindingsregardingtheeffectofRamadanon
theincidenceofacuteappendicitisareinconsistent.In
twoofthestudiesonlypatientsaged15to70years
wereincluded,sincechildrenareexemptfromfasting
andtheelderlymightbeunabletofastandarethere‐
forealsoexempt.[14,15]However,thiswasnottakeninto
considerationinthethirdstudy.[16]Thethreestudies
wereallretrospectivestudies.

Although,thefindingsofbothcohortstudieseva‐
luatingtheeffectoffastingonPUDpatientsonH2‐
blockertreatmentwereinagreement,bothstudieshad
somelimitations.[17,18]Inbothstudies,allofthepatients
inthenon‐fastinggrouptooktheprescribeddrugreg‐
ularly,while14.03%and21.73%ofthepatientsinthe
fastinggroupweredrugdefaultersinthefirstandthe
secondstudy,respectively.Theauthorsofthefirst
studyalsostatedthatthesmallsamplesizewasanoth‐
erlimitationoftheirstudy.[17]

DUulcerhealinginpatientsreceivingOmeprazole,
aprotonpumpinhibitordrug,seemstonotbenega‐
tivelyaffectedbyfasting.[19,20]Mehrabianetal.explain
thattheuseofprotonpumpinhibitorsandHelicobac‐
terpylorieradicationplayanimportantroleinthe
treatmentofDU,andpatientsundertreatmentcanfast
andwillnotfaceanincreasedriskofcomplications.[20]

Ithasevenbeenclaimedthatlong‐termhunger
maycontributetohealingofpersistentulcersbyim‐
provingthecontrolofstomachsecretion.[31]

HealthyindividualsonlyexperienceminorGI
symptomsandnoseriouscomplicationhasbeenre‐
ported.Individualshavingalightmeallikebreakfast
forSahurwerenotsignificantlydifferentfromthose
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Sadeghpour, et al.: Ramadan fasting and digestive disorders
| March 2012 Special Issue (1)| Journal of Research in Medical Sciences S157
havingalargemeal,intermsofincidenceofGIsymp‐
toms.FastingwomentendedtobeaffectedbyGI
symptomsmorethanfastingmen.[21]

InthetwostudiesevaluatingtheincidenceofPUD,
thenumberofpatientspresentingwithPUDwashigher
inthemonthafterRamadancomparedtothatofRama‐
dan.[9,22]

Experimentscarriedoutwithratshavedefinitely
shownulcer‐formingeffectsoflong‐termhunger.[32‐34]
Inanimalstudies,theulcerinducingeffectoflong‐
termhungerwasmostlyrelatedtotheweakeningof
thedefensemechanisms,especiallybyreducingthe
volumeofthemucus.[33]Thefactthatdrinkingofwater
isalsoprohibitedfromdawntosunsetduringfasting
maycauseweakeningofanotherdefensefactorby
leadingtodehydration.[25]

Ithasbeenreportedthatinhumans,the24‐hour
meangastricpHdecreasesafterthe10thdayoffasting.
ThisdecreasecouldcontributetoaggravationofPUD
inpatients.Moreover,theincreaseingastricacidity
wasobservedduringtheday(i.e.fastinghours),which
suggestsgivingantiulcerdrugsaslateaspossibleat
nightduringRamadaninfastingpatients.[35]

ThemajorityofstudiesshowthatPPUingeneral
andDUPinparticular,increaseduringRamadan.All
ofthestudiesonthismatterwereretrospective.Inone
study,itwasreportedthatinthegroupofpatients
withPPU,Inonestudy,itwasreportedthatinthe
groupofpatientswithPPU,theaverageageofwomen
washigherduringRamadan(p<0.01),whiletheaver‐
ageageofmenwassignificantlylowerduringRama‐
dan(0.05>p>0.01),bothcomparedtotheaverage
agesinperiodsbeforeandafterRamadan.[25]

Tavakkolietal.reportedthatalthoughfastingim‐
posesphysiologicalstressonthebody,itdoesnothave
asignificantdeterioratingeffectonIBDpatientsinre‐
mission.TheysuggestedthatIBDpatientswhowerein
remissionandonmaintenancetherapywithnocomor‐
bidities,mightfast.However,thesamplesizeofthe
studywassmallandtherewerelimitationsindatacol‐
lection,astheauthorsstated.[10]

AUGIBwasshowntobemorefrequentduringRa‐
madanbutnostatisticallysignificantdifferencewas
foundbetweenfastingandnon‐fastingpatientsregard‐
ingtheoutcomeofAUGIB.Although,onestudyfound
alowermortalityrateinthefastinggroup,authorsex‐
plainedthatthedifferencemightbeduetotheyounger
ageinthisgroup;patientsinthenon‐fastinggroup
wereolder,sincetheelderlyaremorelikelytobeuna‐
bletofast.[13]

Findingsontheincreaseinprimarysmallbowel
volvulus,[28]mesentericischemia,[3]andhyperemesis
gravidarum,[29]andthedecreaseinidiopathicintussus‐
ception[30]remaintobeinvestigatedmore,beforeade‐
finitiveconclusioncanbemade.

Studiesshowthatgenerally,peoplewithvarious
diseasesareatahigherriskofcomplicationsdueto
Ramadanfasting.Thismightbeinpartbecausepa‐
tientsʹ compliancewithmedicationtherapydrastically
decreasesduringRamadan.Thisisamatterofsignific‐
anceespeciallysincepatientswithchronicdiseases
ofteninsistonfasting,eventhoughtheyarenotper‐
mittedtobytheIslamicrules.Thesepatientstendto
changetheintaketimeanddosingofdrugsarbitrarily
andwithouttakingmedicaladvice.[36]

Giventhatahighpercentageofthesocietystrug‐
gleswithGIdiseases,andconsideringthatareported
numberofapproximatelyonebillionMuslimspartake
inthefastofRamadaneachyear,[37]theimportanceof
conductingstudiestoevaluatetheGIeffectsofRama‐
danfastingisabundantlyclear.Todrawadefinitive
conclusion,furtherstudieswithlargersamplesizeare
required.Moreover,studiesonsomeprevalentGIdis‐
orders,suchasthefunctionalGIdisorders,arelacking
andsuchstudiesarerecommendedtobeconductedin
thefuture.

Inaddition,thisreviewprovidesbackground
knowledgefortheRamadantrackofTheStudyonthe
EpidemiologyofPsychological,AlimentaryHealthand
Nutrition(SEPAHAN).[38]Thedataofthisstudywill
estimatetheimpactofRamadanfastingoncommonGI
symptomsalterationthatwillbepublishedlaterbythe
samestudygroup.

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Sadeghpour, et al.: Ramadan fasting and digestive disorders
S158 Journal of Research in Medical Sciences | March 2012 Special Issue (1) |
How to cite this article: Sadeghpour Sh, Keshteli AH, Daneshpajouhnejad
P, Jahangiri P, Adibi P. Ramadan fasting and digestive disorders:
SEPAHAN systematic review No. 7. J Res Med Sci 2012; 17(Spec 1):
S150-S158.
Source of Support: This study was financially supported by Vice Chancel-
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Conflict of Interest: None declared.
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