Effect of Islamic Ramadan fasting on peptic ulcer perforation: A retrospective comparative study

Abstract

Background: Fasting for extended periods of time increases gastric acid and pepsin levels and consequently the risk of peptic ulcer perforation (PUP). The effects of Ramadan fasting on PUP have not been thoroughly studied, and a few existing studies report contradictory findings. The present study compares patients with PUP operated during the Islamic Ramadan fasting to those operated outside this period and determines whether an association between Ramadan fasting and PUP exists. Patients and methods: A retrospective cross-sectional study between June 2019 and December 2020 was conducted at the Al-Nasr Hospital in the city of Ibb in Yemen. All adult patients operated for a PUP were included. Patient demographic characteristics, risk factors for peptic ulcer, ultrasound and radiological findings on admission, operative findings, postoperative complications, and outcomes were collected from the Hospital Medical Records. Patients were divided into two groups for comparison. Group A included the patients operated on during Ramadan, while Group B included patients operated on outside Ramadan. Results: A total of 40 adult patients with PUP were included. The overall mean age of the participants was 41.6 ± 8.21 years (range: 23–58 years). Most patients were men (30, 75%), and most (19, 47.5%) were admitted to the Al-Nasr Hospital between 24 and 48 hours from the start of the symptoms. History of chewing khat, consumption of nonsteroidal anti-inflammatory drugs, dyspepsia, alcohol use, and smoking were presented in 39 (97.5%), 30 (75%), 36 (90%), 6 (15%), and 35 (87.5%) patients, respectively. The most presented blood group (57.5% of patients) was O type. Most of the patients (72.5%) presented with multiple gastrointestinal symptoms such as abdominal pain, anorexia, vomiting, and constipation. An x-ray found air under the diaphragm in 85% of the patients. Ultrasonography found free fluid in 20 (50%) patients. The size of the perforated ulcer (diameter) was less than 10 mm in 65% of the patients. Postoperative complications were surgical site infection, fluid collection, need for reoperation, and intra-abdominal sepsis in 6 (15%), 4 (10%), 3 (7.5%), and 3 (7.5%) patients, respectively. Most patients (37, 92.5%) recovered well and were discharged from the hospital, and three (7.5%) patients died. The comparative analysis demonstrated a significantly younger age in those operated during Ramadan fasting (Group A) compared to those operated at other times of the year (Group B; 38.8 ± 7.42 years vs. 44.4 ± 8.17; p = 0.029). We observed a statistically significant increase in the number of patients with PUP operated on during Ramadan (p = 0.006), compared to those operated at other times of the year. There was no statistically significant difference between groups in demographic factors, radiologic findings, operative findings, or outcomes (p ≥ 0.05). During the ultrasound, ascites were more frequently diagnosed in group A patients, while acute appendicitis was generally misdiagnosed in Group B patients, a statistically significant difference (p = 0.013). Conclusions: The findings of the present study report an increase in the number of PUP operations during Ramadan fasting in Yemen, but not in postoperative complications, suggesting an association between Ramadan fasting and PUP.