The Journal of International Medical Research
2009; 37: 1988 – 1993
Does Ramadan Fasting Increase Acute
Upper Gastrointestinal Haemorrhage?
S ÖZKAN1, P DURUKAN1, O AKDUR1, A VARDAR1, E TORUN2
1
Department of Emergency Medicine, and 2Department of Gastroenterology, Erciyes
University Medical School, Kayseri, Turkey
The epidemiological characteristics and
clinical results of patients who presented
with acute upper gastrointestinal
haemorrhage (AUGIH) during the month
of Ramadan (October 2007) were
compared with those who presented with
AUGIH during another, non-Ramadan,
month (December 2007). The following
were evaluated: age, gender, symptoms,
gastrointestinal disease history, risk
factors, co-existing diseases, results of
rectal, nasogastric and endoscopic
examinations, treatment modalities and
clinical outcomes. Significantly more
patients were diagnosed with AUGIH
during Ramadan compared with the non-
KEY WORDS: ACUTE UPPER GASTROINTESTINAL HAEMORRHAGE;
EMERGENCY
Introduction
Ramadan is the ninth lunar month of the
Muslim year, during which it is obligatory
for all healthy adult Muslims to observe a
fast from dawn to sunset.1 People may eat or
drink at night but not during the day. After
sunset they consume a large meal called
‘Iftar’ and the last meal they consume is
‘Suhur’ just before ‘fajr’ (dawn) prayers.1 – 3
Acute upper gastrointestinal haemorrhage
(AUGIH) is a life-threatening and commonly
encountered condition that requires
immediate treatment and careful
monitoring.1 The incidence of AUGIH is
1988
AND I IKIZCELI1
Ramadan month (43 versus 28,
respectively). Significantly more patients
diagnosed during Ramadan had a history
of previous haemorrhage compared with
the non-Ramadan month (72.1% versus
42.9%, respectively). Peptic ulcer was the
most common event in both groups and
overall endoscopy findings differed
between the groups. No other significant
differences were found. In conclusion, the
number of patients presenting with
AUGIH during Ramadan was significantly
higher than that of an ordinary month,
which suggests that fasting during
Ramadan reactivates and aggravates pre-
existing gastrointestinal diseases.
RAMADAN; FASTING; ENDOSCOPY;
MEDICINE
reported to be in the range 100 – 150/
100 000 people worldwide.4 – 8 Previous
studies have shown gastric acid and pepsin
levels to increase during Ramadan
compared with periods before and after,9 – 11
indicating a potential risk of adverse
gastrointestinal events during this period.
The present study was designed to
evaluate the epidemiological characteristics
and clinical results of patients who
presented to the emergency department
with AUGIH during the month of Ramadan,
and to compare them with a non-Ramadan
month.
 S Özkan, P Durukan, O Akdur et al.
Ramadan and acute upper gastrointestinal haemorrhage
Patients and methods
PATIENTS AND DATA COLLECTION
This prospective, observational study included
patients aged > 16 years who presented to the
Department of Emergency Medicine, Erciyes
University Medical School (Kayseri, Turkey)
with AUGIH. The study was conducted over
two periods: during October 2007 (group 1),
which was the month of Ramadan; and
during December 2007 (group 2), which was a
non-Ramadan month. Data were collected on
age, gender, symptoms (haematemesis and
melaena), gastrointestinal disease history
(previous gastrointestinal haemorrhage,
peptic ulcer, erosive gastritis, oesophageal
varices, malignancy, haemorrhoids), risk
factors (medications and social/dietary
habits), co-existing diseases, results of rectal,
nasogastric and endoscopic examinations,
treatment modalities and clinical outcomes.
The study protocol was approved by Kayseri
City Local Ethical Committee and all patients
provided written informed consent before
participating in the study.
STATISTICAL ANALYSIS
The data obtained were evaluated using the
SPSS® statistical package, version 15.0 (SPSS
Inc., Chicago, IL, USA) for Windows®. The
Mann–Whitney U-test was used to compare
the results from the two groups. A P-value
< 0.05 was considered to be statistically
significant.
Results
Table 1 presents the demographic and
clinical characteristics of the 71 patients
included in this study during the two study
periods. The overall number of patients
diagnosed with AUGIH during Ramadan
was statistically significantly higher than
those diagnosed during the non-Ramadan
month (43 versus 28, respectively; P < 0.05).
The majority of patients were male (69.8% in
1989
group 1 and 71.4% in group 2) and the
mean ± SD age for the two groups was 57.2 ±
15.1 years for group 1 and 58.6 ± 17.0 years
for group 2; no statistically significant
differences were found between the groups in
terms of gender or age. A total of 72.1% of
patients in group 1 and 42.9% of patients in
group 2 had a history of previous upper
gastrointestinal haemorrhage and this
difference was statistically significant
between the two groups (P < 0.05). Peptic
ulcer was found to be the most common
event in the gastrointestinal disease histories
of both groups. No statistically significant
differences were found between the two
groups regarding medication use, alcohol
consumption, cigarette smoking and
medical symptoms.
In terms of co-existing diseases amongst
patients in group 1, cardiac diseases were
found in 12 (27.9%) patients, hypertension
in 10 (23.3%), a history of cerebrovascular
disease in five (11.6%), diabetes in one
(2.3%) and chronic obstructive pulmonary
disease in one (2.3%) patient. In group 2,
cardiac diseases were found in seven (25.0%)
patients, hypertension in eight (28.6%) and
diabetes in one (3.6%) patient. There were no
statistically significant differences between
the two groups for co-existing diseases.
During rectal examination, 90.6% of
patients in group 1 and 82.2% of patients in
group 2 exhibited melaena. A nasogastric
catheter was not inserted into four patients
in group 1 or into two patients in group 2.
Evaluation with a nasogastric catheter
revealed haematemesis in 39.6% of patients
in group 1 and 28.6% of patients in group 2.
Table 2 presents the findings of the
endoscopic examinations, the treatment
modalities used following diagnosis of
AUGIH and the clinical outcomes. The
overall endoscopy findings were significantly
different between group 1 and group 2
 S Özkan, P Durukan, O Akdur et al.
Ramadan and acute upper gastrointestinal haemorrhage

TABLE 1:
Demographic and clinical characteristics of the patients (n = 71) with acute upper
gastrointestinal haemorrhage stratified according to the month of admission
Group 1 Group 2
Ramadan month Non-Ramadan month Statistical
Characteristic (n = 43) (n = 28) significancea
Gender, n (%) NS
Female 13 (30.2) 8 (28.6)
Male 30 (69.8) 20 (71.4)
Previous upper GI haemorrhage, n (%) P < 0.05
Yes 31 (72.1) 12 (42.9)
No 12 (27.9) 16 (57.1)
GI disease history, n (%) NS
Peptic ulcer 24 (55.8) 17 (60.7)
Erosive gastritis 9 (20.9) 1 (3.6)
Oesophageal varices 5 (11.6) 2 (7.1)
Malignancy 1 (2.3) 0
Haemorrhoids 1 (2.3) 0
Medication use, n (%) NS
NSAIDs and aspirin 21 (48.8) 16 (57.1)
Antiaggregants 5 (11.6) 2 (7.1)
Glucocorticoids 2 (4.7) 0
Social/dietary habits, n (%) NS
Alcohol consumption 6 (14.0) 3 (10.7)
Cigarette smoking 21 (48.8) 14 (50.0)
Symptoms, n (%) NS
Haematemesis 24 (55.8) 16 (57.1)
Melaena 36 (83.7) 22 (78.6)
Signs, n (%) NS
Haematemesis (nasogastric catheter) 17 (39.6) 8 (28.6)
Melaena (rectal examination) 39 (90.6) 23 (82.2)
aMann–Whitney U-test.
NS, not statistically significant (P > 0.05); GI, gastrointestinal; NSAIDs, non-steroidal anti-inflammatory drugs.

patients (P < 0.05); more patients who
presented during Ramadan had a gastric
ulcer (30.2%) or erosive gastritis (11.6%)
compared with those who presented during
the non-Ramadan month (21.4% and 3.6%,
respectively). There was also a much higher
percentage of duodenal ulcer in the non-
Ramadan month (25.0%) compared with the
Ramadan month (11.6%), although this
may be due to the selection of patient groups
and the small number of patients. There
were no statistically significant differences
between the two groups in terms of
treatment modalities for AUGIH or patient
outcomes, although more patients in group
1 (Ramadan month) received blood
replacement therapy and were admitted to
the intensive care unit.
Discussion
People who adhere to Islam do not eat or
drink between certain hours of the day for 1
month, which is known as the month of
Ramadan. This period varies between 12 –
16 h/day depending on the season (summer
or winter).1

1990
 S Özkan, P Durukan, O Akdur et al.
Ramadan and acute upper gastrointestinal haemorrhage

TABLE 2:
Endoscopy findings, treatment modalities and outcomes of patients (n = 71) with acute
upper gastrointestinal haemorrhage stratified according to the month of admission
Group 1 Group 2
Ramadan month Non-Ramadan month Statistical
Characteristic (n = 43) (n = 28) significancea
Endoscopy findings, n (%) P < 0.05
Gastric ulcer 13 (30.2) 6 (21.4)
Duodenal ulcer 5 (11.6) 7 (25.0)
Oesophageal varices 6 (14.0) 5 (17.9)
Non-erosive gastritis 6 (14.0) 3 (10.7)
Erosive gastritis 5 (11.6) 1 (3.6)
Oesophagitis and oesophageal ulcer 2 (4.7) 4 (14.3)
No pathological finding 1 (2.3) 1 (3.6)
Endoscopy was not used 5 (11.6) 1 (3.6)
Treatment, n (%) NS
Blood replacement 37 (86.0) 18 (64.3)
Omeprazole 41 (95.3) 28 (100.0)
Somatostatin 8 (18.6) 2 (7.1)
Antiemetic 21 (48.8) 9 (32.1)
Sclerotherapy 10 (23.3) 6 (21.4)
Band ligation 3 (7.0) 2 (7.1)
Surgery 0 1 (3.6)
Outcomes, n (%) NS
Admission to Gastroenterology 26 (60.5) 17 (60.7)
Admission to ICU 9 (20.9) 3 (10.7)
Discharge 8 (18.6) 7 (25.0)
Admission to General Surgery 0 1 (3.6)
aMann–Whitney U-test.
NS, not statistically significant (P > 0.05); ICU, intensive care unit.

Studies have shown that gastric acid levels
increase during Ramadan.9,10 Iraki et al.11
showed a 45% rise in 24-h (H+) activity
during Ramadan compared with the period
before Ramadan and this was maintained
throughout the entire Ramadan period. They
also found a 23% elevation in 24-h (H+)
activity in the month after Ramadan
compared with the value before Ramadan.11
Hakkou et al.10 reported elevations in acid
and pepsin secretions during Ramadan
while finding reductions in those levels after
Ramadan.
Studies have shown that peptic ulcers
constitute 45 – 60% of all AUGIH cases
presenting to hospitals worldwide.4,6,12,13 The
design of the present study was based on the
prediction that the incidence of peptic ulcer,
gastritis and AUGIH would rise in parallel
with the elevation in gastric acid secretion
among people who fasted during Ramadan.
It was found that the number of patients
presenting with AUGIH during Ramadan (n
= 43) was significantly higher than that of
another non-Ramadan month (n = 28).
Dönderici et al.3 showed higher peptic
ulcer complications during Ramadan
compared with the periods before and after
Ramadan. Malik et al.1 observed
haemorrhage in eight of 23 patients with

1991
 S Özkan, P Durukan, O Akdur et al.
Ramadan and acute upper gastrointestinal haemorrhage

peptic ulcer who fasted, whereas they found
no haemorrhage among 15 patients who did
not fast. Kapicioğlu et al.14 found no
elevation in the frequency of AUGIH during
Ramadan and reported that the reason
behind the difference was seasonal. In the
current study, peptic ulcer was the most
frequent underlying cause in patients who
presented with AUGIH in both of the time
periods, and no significant difference was
observed between them.
Malik et al.1 found both haematemesis
and melaena in four patients with
gastrointestinal haemorrhage who fasted
and melaena alone in another four.1
Melaena occurred in 90.6% and
haematemesis occurred in 39.6% of patients
in the present study who presented during
Ramadan, while the rates were 82.2% and
28.6% for patients who presented during the
non-Ramadan month, respectively.
Aksoy et al.15 found no significant
difference between the diagnoses established
by endoscopy before and after Ramadan.
Another study determined no increase in
peptic ulcer incidence between the Ramadan
period, and the periods before and after
Ramadan.2 In contrast, in the present study,
there was a significant difference between
the patient group who presented during
Ramadan and the group who presented
during another non-Ramadan month with
regard to overall endoscopic findings.
A higher percentage of patients in the
present study who presented during
Ramadan had a history of previous upper
• Received for publication 22 June 2009 • Accepted subject to revision 1 July 2009
• Revised accepted 16 October 2009
Copyright © 2009 Field House Publishing LLP
gastrointestinal haemorrhage compared
with patients who presented in the non-
Ramadan month (72.1% versus 42.9%,
respectively). This compares with a study by
Fiore et al.,13 between 1996 and 2000,
unrelated to the potential effects of
Ramadan, in which 19 – 23% of patients had
a history of previous AUGIH. Thomopoulos
et al.6 found a similar rate (33%) in their
study between the years of 1986 and 1987
but only 6% between 2000 and 2001.
Many studies have shown a relationship
between NSAID/aspirin use and
AUGIH12,16,17 and the more recent studies
have reported the rate to be 40 – 65%.4,6
During Ramadan, particularly as a result of
the increased levels of gastric acid due to
fasting, the interaction of these drugs may
lead to further elevations in the incidence of
AUGIH. In the present study, 48.8% of
patients presenting during Ramadan and
57.1% of patients presenting during a non-
Ramadan month had a history of
NSAID/aspirin use.
In conclusion, the number of patients
presenting with AUGIH during Ramadan
was significantly higher than for a non-
Ramadan month. Fasting during Ramadan
seems to reactivate and aggravate the
severity and complications of pre-existing
gastrointestinal diseases like peptic ulcer and
gastritis.
Conflicts of interest
The authors had no conflicts of interest to
declare in relation to this article.

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Author’s address for correspondence

Assistant Professor Seda Özkan
Yenidoğan Mh. Fatih Cd, Fatih Siteleri D Blok No. 21, 38039 Talas, Kayseri, Turkey.
E-mail: sedacil@yahoo.com

1993