Does Ramadan Fasting Increase Duodenal Ulcer Perforation?

Document Type : Research Paper


1 Departments of General Surgery, Trauma Research Center, Kashan University of Medical Sciences, Iran

2 Department of Biostatistics and Epidemiology, Social Determinants of Health (SDH) Research Center, Kashan University of Medical Sciences, Kashan, Iran


Introduction: In Ramadan, healthy adult Muslims are obliged to fast. Prolonged fasting increase gastric acid and pepsin levels, which promote the risk of duodenal ulcer perforation (DUP). Effects of Ramadan fasting on DUP have not been thoroughly studied yet, and the limited number of studies investigating the impact of Ramadan fasting on DUP yielded discrepant results. This study aimed to evaluate DUP frequency during Ramadan 2011-2015 and compare it with other months. Methods: This cross-sectional study was performed in 82 patients undergoing surgery due to DUP during July 2011-September 2015. The demographics, history of addiction, use of nonsteroidal and antiinflammatory drugs, previous history of acid peptic disease, as well as complications and outcomes of treatment were recorded and analyzed, and the obtained results were compared between Ramadan and other lunar months. Results: The majority of patients were male (86.6%, 71 patients), with a mean age of 43.9±16.5 years (age range: 20-75 years). Male to female ratio was 6:1. Cases with less than 30 years of age were less frequent (22%, 18 patients). DUP was more frequent during Rajab with nine cases (11%), while during Ramadan, six cases were reported, the difference between Ramadan and other months regarding the incidence of DUP was not significant (P=0.7). Risk factors such as smoking (60%) and addiction (44%; especially to crystal and crack) were noted. Consumption of nonsteroidal antiinflammatory drugs in 20 (24%) patients, and use of antacids in 17 (25%) patients. Distribution of DUP in different blood types was as follows: O+=41%, A+=28%, B+=23%, AB=5%, and O-=3%; moreover, post-operative Helicobacter pylori antibody was present in 67% of the patients. Conclusion: Ramadan fasting did not escalate DUP incidence, and those with DUP risk factors can fast with the use of antacids.


  1. Nomani MZ, Khan AH, Shahda MM, Nomani AK, Sattar SA. Predicting serum gastrin levels among men during Ramadan fasting. East Mediterr Health J. 2005; 11(1-2):119–25.

  2. Azizi F. Islamic fasting and health. Ann Nutr Metab. 2010; 56(4):273–82.
  3. Elnagib E, Mahadi SE, Ahmed ME. Perforated peptic ulcer in Khartoum. Khartoum Med J. 2008; 1(2):62-4.
  4. Kucuk H, Censur Z, Kurt N, Ozkan Z, Kement M, Kaptanoglu L, et al. The effect of Ramadan fasting on duodenal ulcer perforation: a retrospective analysis. Indian J Surg. 2005; 67(4):195-8.
  5. Gocmen E, Koc M, Tez M, Yoldas O, Bilgin A, Keskek M. Effect of Ramadan on surgical emergencies. Ann Emerg Med. 2004; 44(3): 283-5
  6. Bener A, Derbala MF, Al-Kaabi S, Taryam LO, Al-Ameri MM, Al-Muraikhi NM, et al. Frequency of peptic ulcer disease during and after Ramadan in a United Arab Emirates hospital. East Mediterr Health J. 2006; 12(1-2):105-11.
  7. Thorsen K, Glomsaker TB, von Meer A, Søreide K, Søreide JA. Trends in diagnosis and surgical management of patients with perforated peptic ulcer. J Gastrointest Surg. 2011; 15(8):1329–35.
  8. Al-Kaabi S, Bener A, Butt MT, Taweel M, Samson S, Al-Mosalamani Y, et al. Effect of Ramadan fasting on peptic ulcer disease. Indian J Gastroenterol. 2004; 23(1):35.
  9. Tiwari A, Moghal M, Melaegros L. Life-threatening abdominal complications following cocaine abuse. J R Soc Med. 2006; 99(2):51–2.
  10. Thorsen K, Soreide JA, Kvaloy JT, Glomsaker T, Soreide K. Epidemiology of perforated peptic ulcer: age- and gender-adjusted analysis of incidence and mortality. World J Gastroenterol. 2013; 19(3):347–54.
  11. Ugochukwu AI, Amu OC, Nzegwu MA, Dilibe UC. Acute perforated peptic ulcer: on clinical experience in an urban tertiary hospital in south east Nigeria. Int J Surg. 2013;11(3):223-7.
  12. Al-Hourani HM, Atoum MF. Body composition, nutrient intake and physical activity patterns in young women during Ramadan. Singapore Med J. 2007; 48(10):906-10.
  13. Amine el M, Kaoutar S, Ihssane M, Adil I, Dafr-Allah B. Effect of Ramadan fasting on acute upper gastrointestinal bleeding. J Res Med Sci. 2013; 18(3):230–3.
  14. Anstee DJ. The relationship between blood groups and disease. Blood. 2010; 115(23): 4635-43.
  15. Bayan K, Tuzun Y, Yilmaz S, Dursun M, Canoruc F. Clarifying the relationship between ABO/Rhesus blood group antigens and upper gastrointestinal bleeding. Dig Dis Sci. 2009; 54(5):1029-34.
  16. Fakhry S, Watts D, Daley B, Enderson B, Liu T, Moore F, et al. Current diagnostic approaches lack sensitivity in the diagnosis of perforating blunt small bowel injury (SBI): findings from a large multi-institutional study. Eastern Association for the Surgery of Trauma, 2002. J Trauma. 2001; 51:1232.
  17. Gokakin AK, Kurt A, Atabey M, Koyuncu A, Topçu O, Aydin C, et al. The impact of Ramadan on peptic ulcer perforation. Ulus Travma Acil Cerrahi Derg. 2012; 18(4):339-43.
  18. Hosseini-asl K, Rafieian-Kopaei M. Can patients with active duodenal ulcer fast Ramadan? Am J Gastroenterol. 2002; 97(9):2471–2.
  19. Torab FC, Amer M, Abu-Zidan FM, Branicki FJ. Perforated peptic ulcer: different ethnic, climatic and fasting risk factors for morbidity in Al-ain medical district, United Arab Emirates. Asian J Surg. 2009; 32(2):95–101.
  20. Taha F, Lipsitz JD, Galea S, Demmer RT, Talley NJ, Goodwin RD. Anxiety disorders and risk of self-reported ulcer: a 10-year longitudinal study among US adults. Gen Hosp Psychiatry. 2014; 36(6):674–9.
  21. Torab FC, Amer M, Abu-Zidan FM, Branicki FJ. Perforated peptic ulcer: different ethnic, climatic and fasting risk factors for morbidity in Al-ain medical district, United Arab Emirates. Asian J Surg. 2009; 32(2):95–101.
  22. Bdioui F, Melki W, Ben Mansour W, Loghmari H, Hellara O, Ben Chaabane N, et al. Duodenal ulcer disease and Ramadan. Presse Med. 2012; 41(9 Pt 1):807–12.

  23. Ozkan S, Durukan P, Akdur O, Vardar A, Torun E, Ikizceli I. Does Ramadan fasting increase acute upper gastrointestinal haemorrhage? J Int Med Res. 2009; 37(6):1988–93.
  24. Wang YR, Richter JE, Dempsey DT. Trends and outcomes of hospitalizations for peptic ulcer disease in the United States, 1993 to 2006. Ann Surg. 2010; 251(1):51-8.
  25. Gilliam AD, Speake WJ, Lobo DN, Beckingham IJ. Current practice of emergency vagotomy and Helicobacter pylori eradication for complicated peptic ulcer in the United Kingdom. Br J Surg. 2003; 90(1):88-90.