Arab Journal of Gastroenterology 13 (2012) 180–183

Contents lists available at SciVerse ScienceDirect

Arab Journal of Gastroenterology

journal homepage: www.elsevier.com/locate/ajg

Short Communication

Effects of Ramadan fasting on peptic ulcer disease as diagnosed by upper

gastrointestinal endoscopy
Ali Kagan Gokakin ⇑, Atilla Kurt, Gunduz Akgol, Boran Cihat Karakus, Mustafa Atabey, Ayhan Koyuncu,
Omer Topcu, Erdal Goren
Cumhuriyet University, School of Medicine, Department of General Surgery, Sivas, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Background and study aims: The diagnostic methods such as upper gastrointestinal endoscopy (UGE) have
Received 31 January 2012 played an important role in the evaluation of peptic ulcer (PU). Every year, millions of Muslims fast in
Accepted 13 December 2012 Ramadan month. The aim of this study was to evaluate the effect of fasting on PU via UGE.
Patients and methods: A total of 321 patients in the period from 2009 to 2011, who underwent UGE as a
diagnostic work-up mainly for epigastric pain, were analysed. Patients were divided into three groups:
Keywords: Patients who have been evaluated by UGE, in the month just before Ramadan (group I, n = 69), in Ram-
Upper gastrointestinal endoscopy
adan month (group II, n = 132) and in the month just after Ramadan (group III, n = 120).
Peptic ulcer
Ramadan
Continuous data were expressed as the mean ± SD, and were compared with one-way analysis of variance
(ANOVA) test amongst groups. Categorical data were given as percentages and were compared with the
chi-squared test.
Results: Epigastric pain was the most common indication for referral in each group. Interestingly, the
indication ‘bleeding’ was found to be the least in group II, but was far from statistical significance. The
highest prevalence of duodenal ulcers and duodenitis was found in group II; the differences to the other
groups were statistically significant.
Conclusion: Duodenal ulcers and duodenitis were found more during Ramadan month. We recommend
that, the patients with epigastric pain may fast by taking their medications.
Ó 2012 Arab Journal of Gastroenterology. Published by Elsevier B.V. All rights reserved.

Introduction
Fasting during the ninth month of the lunar calendar (Ramadan)
is a religious obligation for most adult Muslims. This entails no
food and liquid intake during daytime. The duration of this restric-
tion varies between 10 and 19 h, depending on which season of the
solar calendar Ramadan coincides with that year (approximately
10 days earlier every year). The effect of Ramadan on the metabo-
lism of the body has been the subject of various publications [1–6].
Further, the association between the time-restricted food, water
intake and gastric pH and plasma gastrin level was discovered a
long time ago [7].
However, some particular effects of this religious practise on
peptic ulcer (PU) have not been thoroughly studied in recent years.
An Indian prospective randomised study in the mid-90s including
23 patients in which all the cases were evaluated by upper gastro-
intestinal endoscopy (UGE) advocated that Ramadan fasting might
prove hazardous in patients with PU disease in general and with
⇑ Corresponding author. Address: Cumhuriyet Üniversitesi Tıp Fakültesi Genel
Cerrahi ABD, 58140 Sivas, Turkey.
E-mail address: dralihan20@hotmail.com (A.K. Gokakin).
active chronic ulcers in particular [8]. However, the number of pa-
tients in that trial was too small to make such conclusion. On the
other hand, a different study using UGE from the United Arab Emir-
ates in 2006 affirmed that there was no significant difference in the
frequency of PU cases in Ramadan when compared to the month
after Ramadan [9]. Furthermore, a recent trial with 1661 patients
published by Chong et al. in 2009 declared that patients referred
during the fasting month of Ramadan had more ulcer diseases, par-
ticularly duodenal ulcers [10]. The conclusions of those three stud-
ies were not in the same direction.
Further, there is still an ongoing debate on PU patients as to
whether they may fast during Ramadan or not. The aim of the
study was to evaluate the effect of Ramadan on PU by considering
the medical conditions of the patients and the pathologic findings
during UGE.
Patients and methods
The study was approved by the local ethics committee. The
study included the patients who were subjected to UGE due to
having symptoms of ulcer disease between 2009 and 2011. The pa-
tients who were in our follow-up due to malignancy or PU were

1687-1979/$ - see front matter Ó 2012 Arab Journal of Gastroenterology. Published by Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.ajg.2012.12.002
 A.K. Gokakin et al. / Arab Journal of Gastroenterology 13 (2012) 180–183 181

Table 1
Demographic and clinical features of patients.

Group I Group II Group III p

(Pre-Ramadan) n = 69 (Ramadan) n = 132 (Post-Ramadan) n = 120
Age (mean ± SD), Years 52.3 ± 16 50.6 ± 15 51.6 ± 18 0.75
Gender
Male 36 (52.2%) 69 (52.3%) 51 (42.5%) 0.24
Female 33 (47.8%) 63 (47.7%) 69 (57.5%)
NSAID 50 (72.5%) 98 (74.2%) 102 (85.0%) 0.57
Smoking 43 (62.3%) 86 (65.2%) 78 (65.0%) 0.91
Co-morbidity 27 (39.1%) 57 (43.2%) 42 (35.0%)
HT 17 (24.6%) 32 (24.4%) 27 (22.5%)
COPD 7 (10.1%) 13 (9.8%) 9 (7.5%) 0.41
DM 2 (2.8%) 10 (7.5%) 4 (3.3%)
Others 1 (1.6%) 2 (1.5%) 2 (1.7%)

Table 2
Indications for UGE.

Group I Group II (Ramadan) n = 132 Group III (Post-Ramadan) n = 120 p

(Pre-Ramadan) n = 69
Epigastric Pain, n (%) 35 (50.7) 84 (63.6) 76 (63.3) 0.38
Dyspepsia, n (%) 8 (11.6) 11 (8.3) 13 (10.8)
Anaemia, n (%) 8 (11.6) 15 (11.49) 12 (10.0)
Bleeding, n (%) 12 (17.4) 9 (6.8) 9 (7.5)
Others, n (%) 6 (8.8) 13 (9.8) 10 (8.3)

Table 3
Medical conditions of the patients at the time of admission
The severity of epigastric pain in patients. were also evaluated. The demographical and clinical features of
the patients according to the groups are given in Table 1. The indi-
Group I (Pre- Group II GroupIII (Post- p
Ramadan) n = 69 (Ramadan) Ramadan) n = 120
cation of the endoscopy of the patients is analysed in Table 2. In the
(%) n = 132 (%) (%) case of epigastric pain, patients were asked to score their pain
Mild 25 (36) 47 (35) 43 (35) 0.31
according to a subjective pain scale. Those scores were classified
Moderate 6 (9) 23 (18) 19 (16) as mild, moderate and severe. The results of the classification were
Severe 4 (6) 14 (10) 12 (10) analysed to detect the existence of any difference amongst groups
Total 35 (51) 84 (63) 74 (61) (Table 3).
Details of endoscopic findings were collected and were catego-
rised into normal and abnormal findings. Abnormal findings were
excluded. Hence, only first-time applicants were included in the further categorised into anatomic parts of upper gastrointestinal
study. systems and the results are shown in Table 4.
Data of the patients were collected prospectively and evaluated The study period was 3 years and the variation of the number of
retrospectively. A total of 321 patients in the period 2009–2011, the admissions in time is shown in Fig. 1.
who underwent UGE mostly to clear up epigastric pain, were ana-
lysed. Patients were divided into three groups: patients who have Statistics
been evaluated via UGE, in the month just before Ramadan (group
I, n = 69), in the Ramadan month (group II, n = 132) and in the Continuous data are expressed as the mean ± SD, and were
month just after Ramadan (group III, n = 120). compared with one-way analysis of variance (ANOVA) test

Table 4
Endoscopic Findings in Groups.

Group I (Pre-Ramadan) n = 69 (%) Group II (Ramadan) n = 132 (%) Group III (Post-Ramadan) n = 120 (%) p
Oesophagus
Normal 50 (72.5) 88 (66.6) 84 (70.0) 0.39
Oesophagitis 12 (17.4) 22 (16.6) 25 (20.8)
Hiatal hernia 7 (10.1) 22 (16.6) 11 (9.2)
Stomach
Normal 2 (2.9) 4 (3) 5 (4.2) 0.51
Gastritis 46 (66.7) 86 (65.2) 88 (73.3)
Ulcer 6 (8.7) 18 (13.6) 12 (10)
Bile reflux 12 (17.4) 15 (11.4) 12 (10)
Bleeding 3 (4.3) 9 (6.8) 3 (2.5)
Duodenum
Normal 49 (71.0) 62 (46.9) 68 (56.7) 0.04⁄
Duodenitis 5 (7.2) 32 (24.2) 22 (18.3)
Ulcer 11 (15.9) 31 (23.5) 25 (20.8)
Bleeding 4 (5.8) 7 (5.3) 5 (4.2)

Duodenal ulcer and duodenitis were detected significantly higher in group II (p = 0.04) than in group I and group III.
182 A.K. Gokakin et al. / Arab Journal of Gastroenterology 13 (2012) 180–183

45
40
35
30
25 Group III
20
Group II
15
10 Group I

5
0
2009 2010 2011

Fig. 1. Patient admissions in years.

amongst groups. Categorical data are given as percentages and been conducted specifically on the effects of Ramadan fasting on
were compared with the chi-squared test. Ordinal data were tested PU disease. The aim of the study was to evaluate the effect of Ram-
with the Kruskal–Wallis test. A p value < 0.05 was considered to be adan on PU by considering the medical conditions of the patients
significant. All statistical analyses were performed using the SPSS and the pathologic findings during UGE.
statistical package for Windows version 15 (Statistical Package In our trial, the demographical data of the patients and the indi-
for Social Sciences (SPSS), Inc., Chicago, IL, USA). cations for endoscopy during the fasting and the non-fasting
months showed minimal differences. These results are similar to
the results of Chong’s study [10]. However, the latter study was
Results
done in a multi-cultural country.
The impact of fasting in ulcer patients was the subject of a few
UGE was done for 321 patients during the study period: Either
trials [9,12]. The severe complications of that disease were found
before (n = 69), during (n = 132) and after (n = 120) the month of
to be higher during Ramadan. However, in our study, there were
Ramadan. There were no significant differences between the ages
no differences in endoscopic findings of the oesophagus and the
and the genders of the patients’ groups (p > 0.05). Further, there
stomach. This difference is difficult to explain. Perhaps the major
were no significant differences between non-steroidal anti-
complications are a consequence of the pathologic findings in the
inflammatory drug (NSAID) usage, smoking habit and existence
duodenum.
of co-morbidity between these three groups (p > 0. 05).
In another study published by Azizi, it was noted that patients
Hypertension (HT), chronic obstructive pulmonary disease (COPD)
with complicated PU should be advised against fasting. However,
and diabetes mellitus (DM) were the most common co-morbidities
asymptomatic patients may try fasting [13]. In our study the endo-
in all groups.
scopic changes were mainly in duodenum; with, an increase in
There were no significant differences in the referral indications
duodenitis and duodenal ulcer.
between the three groups (p = 0.38). Interestingly, the indication
Duration of fasting may have an effect on the results in all trials.
‘bleeding’ was found to be the least in group II, but was far from
The duration of fasting varies between 10 and 19 h in our country,
statistical significance. The highest prevalence of duodenal ulcers
depending on which season of the solar calendar Ramadan coin-
and duodenitis was found in group II; the differences to the other
cides with that year (approximately 10 days earlier every year).
groups were statistically significant.
Hence, it is certain that this study has some limitations. Finding
The severity of epigastric pain was evaluated by a subjective
out all the data requires a perspective of 36 years because Rama-
pain scale. No significant differences were detected between
dan completes its one tour around the solar calendar in 36 years.
groups either (p = 0.31). Epigastric pain was more frequent in
Further, this study can reflect only the results of one region in Tur-
group II but was far from statistical significance.
key, but there are more than one billion Muslims all over the world
Similarly, there were no significant differences in the endo-
who are fasting under different conditions and for different
scopic findings in the oesophagus and stomach. Gastritis and
durations.
oesophagitis were detected as the most frequent abnormal find-
We can conclude for our population that duodenal ulcers and
ings in stomach and oesophagus in each group. On the other hand,
duodenitis were found more often during the period of Ramadan.
duodenal ulcer and duodenitis were detected significantly higher
The other parameters were found similar in the Ramadan group.
in group II (p = 0.04) than in group I and group III.
We recommend, that the patients with epigastric pain may take
antisecretory agents such as proton pump inhibitors during the
Discussion period of Ramadan fasting.

Whether PU disease patients should be recommended not to Conflict of interest

fast is a difficult question to respond to, because the physiological
changes during Ramadan are not precisely known. In the modern
era of H2-receptor blocker, proton pump inhibitors and eradication
of Helicobacter pylori, the treatment for PU disease had already led
to a sharp decline in complications.
It is well known that gastrointestinal disorders can be affected
by fasting. Recently, only few studies were published, which have
focussed on the impact of Ramadan on peptic disorders and all
these studies have different results [1,4,11]. So far, no study has
The authors declared that there was no conflict of interest.
References
[1] 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.
[2] Fedail SS, Murphy D, Salih SY, et al. Changes in certain blood constituents
during Ramadan. Am J Clin Nutr 1982;36(2):350–3.
 A.K. Gokakin et al. / Arab Journal of Gastroenterology 13 (2012) 180–183
[3] Ramadan J, Telahoun G, Al-Zaid NS, et al. Responses to exercise, fluid and
energy balances during Ramadan in sedentary and active males. Nutrition
1999;15(10):735–9.
[4] Larijani B, Zahedi F, Sanjari M, et al. The effect of Ramadan fasting on fasting
serum glulcose in healthy adults. Med J Malaysia 2003;58(5):678–80.
[5] Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of
diabetes during Ramadan: update 2010. Diabetes Care 2010;33(8):1895–902.
[6] Ghouri N, Gatrad R, Sattar N, et al. Summer-winter switching of the Ramadan
fasts in people with diabetes living in temperate regions. Diabet Med
2012;29(6):696–7.
[7] Halberg F. Protection by timing treatment according to bodily rhythms – an
analogy to protection by scrubbing before surgery. Chronobiologia
1974;1(Suppl. 1):27–72.
183
[8] Malik GM, Mubarik M, Jeelani G, et al. Endoscopic evaluation of peptic ulcer
disease during Ramadan fasting: a preliminary study. Diagn Ther Endosc
1996;2(4):219–21.
[9] Bener A, Derbala MF, Al-Kaabi S, 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.
[10] Chong VH. Impact of Ramadan on upper gastrointestinal endoscopy referrals
in Brunei Darussalam. Singapore Med J 2009;50(6):619–23.
[11] Hosseini-asl K, Rafieian-kopaei M. Can patients with active duodenal ulcer fast
Ramadan? Am J Gastroenterol 2002;97(9):2471–2.
[12] Donderici O, Temizhan A, Kucukbas T, et al. Effect of Ramadan on peptic ulcer
complications. Scand J Gastroenterol 1994;29(7):603–6.
[13] Azizi F. Islamic fasting and health. Ann Nutr Metab 2010;56(4):273–82.