Effect of Ramadan Fasting Among Muslims on the Frequency of Perforated Peptic Ulcer, a Retrospective Study

Effect of Ramadan Fasting Among Muslims on the Frequency of Perforated Peptic Ulcer, a Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of Ramadan Fasting Among Muslims on the Frequency of Perforated Peptic Ulcer, a Retrospective Study Saman Taher Barzinjy This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8719342/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: peptic ulcer is a chronic lesion that occurs in any portion of GIT (usually stomach), it is exposed to the aggressive action of acid peptic juice, this disease has been broadly treated medically, peptic ulcer has numbers of complications still perforation is one of the commonest and severe form of complications, if happened it should be treated as soon as possible. Objectives: To assess the effect of fasting among Islamic people during Ramadan month on peptic ulcer perforation in Erbil province. Patients and Methods: a retrospective study of 86 Patients who underwent operation for perforated peptic ulcers (gastric and duodenal) in an emergency Hospital of Erbil City – Kurdistan Region - Iraq between the period of October 2016 and August 2021 were coincide the period between (60 lunar months) were analyzed. Patients divided into two groups. Group I (No. 77) included those who were underwent operation throughout other months of the years except the Ramadan (fasting month) while Group II (No.9) constituted of those patients who were underwent operation throughout the Ramadan (fasting month). Results: No statistically significant difference in the mean ages between the groups (40.26 vs. 48.11 years) observed. The mean monthly number of surgical intervention rates was slightly higher in Ramadan months, generally male patients are predominating in peptic ulcer perforation during Ramadan. Conclusions: Occurrence of peptic ulcer perforation was relatively higher during Ramadan months, with male predominance. General Surgery Ramadan fasting and peptic ulcer perforated peptic ulcer and Ramadan fasting Ramadan effect on peptic ulcer perforation Figures Figure 1 Figure 2 Figure 3 Introduction However, their reduction in the evidence in the last decades, perforation of peptic ulcers has still been an essential issue with its high frequency in emergency clinics and hospitals ( 1 , 2 ). The 9th lunar month of the lunar calendar is Ramadan, which is the fasting month of the Muslim populations worldwide. This lunar calendar annually pushes the solar year of the Gregorian calendar by about 11 days earlier, since the Islamic year had been based on the lunar calendar, which contains 354 days. Fasting for long durations from Morning Prayer to evening prayer is technically difficult in some seasons, especially in Polar Regions and countries, where Muslims, in fact, will use local Arabic calendars, which unfortunately is not always approved by local religious Islamic representatives in those countries. In summary, fasting during the month of Ramadan is a total but intermittent fast throughout the whole daylight. In spite of medical treatment that has been broadly used in peptic ulcer diseases, peptic ulcer perforation still remains as a severe complication of the disease. because perforation of the alimentary tract organs may give rise to septic complications and even death, the purpose of the present study is based on the common correlation between Ramadan fasting and peptic ulcer perforation, which can be seen as an international issue because of migrations of large amount of Muslims populations to almost all countries throughout the last decades during our era of globalization. One of the five sine qua non of Islam is fasting throughout all the days of the holy Ramadan month. Fasting as a religious ritual from the perspective of the need for emergency surgical intervention because of perforated peptic ulcer has not been studied even in recent years. Many developments were awaited in that common complication of emergency applications; however, even conservative medical treatment has evolved for perforated peptic ulcers in selected cases. ( 3 ) Nowadays the prophylactic surgical intervention of peptic ulcer disease is abandoned because of the revolutions in the medications and successful conservative treatment options during the last decades; in spite of this, the frequency of perforated peptic ulcer is still high. This is the point of debate regarding whether Ramadan fasting is dangerous in a selected group of patients or not. Hence, some new visions regarding the relationship between fasting and perforated peptic ulcer in the era of conservative treatment are necessary, at least in a global era with a high frequency of vocations for tourism and large numbers of immigration. Because the Islamic fasting is a total fasting of both fluid and solid foods from the time of morning prayer to evening prayer time, this provides a unique physiological model, which is varies from experimental and voluntary fasting types. Analysis of the effect of fasting on perforated peptic ulcer will be complicated and challenging because Ramadan month will shift 11 days forward annually; this will lead to increased fasting periods in summers and decreased in winters. The avoidance of any liquid or food intake may last about 10–19 hours depending on solar calendar and the season of countries. Moreover, the rate of fasting time change continues to raise more in the countries that are located in the North or South because fasting period is between sunrise and sunset. Unfortunately, while Ramadan coincides with winter months, fasting hours are the minimum, but while Ramadan is in summer, the fasting hours are longest. Since during Ramadan months, increasing the emergency presentation of some diseases has been well established, it has been a well-known fact that occurrences of duodenitis, duodenal ulcers, and perforated peptic ulcers as well were more common throughout Ramadan months ( 4 – 9 ). It has been estimated that fasting throughout Ramadan month will increase the gastric acidity over critical range, especially through the hours of the day time. The gastric acidity reaches its peak at the end hours of the fasting period. Hence, the rate of ulcer complications is statistically higher during Ramadan in comparison to other months. The frequency of the upper gastrointestinal bleeding is doubled, and perforation is estimated to be four times more than normal during those days ( 10 ). During fasting, pregnancy is also a factor resulting in perforated peptic ulcer ( 11 ). Ketoacidosis or hypoglycemia is a well-known and studied complication of diabetes mellitus during the Ramadan month ( 12 – 15 ). Even infections have a role in increasing peptic ulcer perforation during Ramadan; this is the finding of 51 articles in a meta-analysis of a systematic review ( 16 ). It is shown that urinary tract infections are also more common throughout fasting time due to dehydration and inadequate fluid intake during the Ramadan month ( 17 ). The changing profile of patients with peptic ulcer and perforated peptic ulcer because of successful use of antiulcer drugs, globalization, mass human migrations, concomitant diseases, and aging of the patients and populations, transforms some former diseases such as peptic ulcers, giving them new profiles. All these mentioned factors necessitate new studies for creating a novel vision for the physicians in our era. The aim of this retrospective study is to assess and find the effect of Ramadan fasting on peptic ulcer perforation in Erbil City, Kurdistan region, Iraq, which is one of the cities where most of the living populations are of the Islamic religion, and to find some clues of recommendations to inform and make patients aware about fasting in Ramadan, especially those complaining of gastrointestinal tract diseases. Patients and Methods This retrospective study includes 86 patients who have been operated on by different general surgery specialists on the basis of the indication of perforated peptic ulcer in East Erbil Emergency Hospital between the period of October 2016 (Muharram of 1438 Hijri year) and August 2021 ( Muhrram of 1442 Hijri year). In the succeeding years, the start and the end of Ramadan shifted 11 days forward, so five Ramadan months included in the study, The 1st Ramadan included in this study was started on 26th May 2017, and the last day of Ramadan in the study was ended on 12th May 2021 but further cases beyond this period also included till August 2021 for the aim of including full 60 months of five Lunar years, so 5 months for each lunar months were included. Patients were classified into two groups. Group I (No. 77) included the patients who had been operated during other months of the lunar years (Muharram, Safar, Rabi al-awwal, Rabi al-thani, Jamada al-awwal, Jamada al-thani, Rajab, Sha’aban, Shawwal, Dhul Qadah, and Dhul hijja) that was constitute 55 months, patients who underwent operation during the fasting month of Ramadan (the remaining 5 months) classified under the Group II (No. 9). The data was taken from a file of patients’ data in the Microsoft Access version 2010 database in the data entry department of East Erbil emergency hospital. The cases were also classified into age groups of less than 20 years, 20–29 years, 30–39 years, 40–49 years, 50–59 years, and 60 and more. The longest day times in Iraq is between 15th May − 15th August, which will reach 14 hr. and more, meanwhile the shortest day time that will be 9 hr. and less is between 21st November and 21st February, these two ranges (each three months) calculated for observing the perforated peptic ulcer rate in long day time and hot weather period (most Ramadan months in this study were located within this long day time period, and the other days were also very close to this period). Permission was taken from the related administrative persons in the hospital, and they were informed that the hospital data could be used for studies and scientific purposes in the future. The data base file contained patients data during the mentioned periods of the years, however some data was not clear and lost regarding age, gender, the exact diagnoses, admission and discharge times, all were excluded from the study, other religions of the patients such as Christian and Yazidi also excluded from the study since they have other religious views and they do not fast during Ramadan, the Microsoft access file contained the data about, name, file number, age, sex, religion, admission and discharge date, specialist responsible, and final diagnosis, surgical method, and mortality. Data entry and statistical analysis were done by the use of the Microsoft Excel program version 2010. P-values calculated by t-test. Results The total number of cases were 86 cases, 69 (80.23%) of them were male and the remaining 17 (19.77%) were female (Figure 1), the age ranged between 11 – 90 years with a mean and SD 41.08 ± 18.40,age group of 20 – 39 years old constitutes nearly half (41 no, 47.67%) of the sample (33 male and 8 females), age group 60 years old and above came in the next frequency by 16 cases (18.6%) of the whole sample (12 male and 4 female), meanwhile least number reported among the group of less than 20 years old ( 4 male and 1 female), again among the age group of 20-39 years and 60 years and above both male and female sex recorded highest incidence in compare to their sex among the other age groups (Table 1). Among the sample, 9 cases (10.46%) were found to develop perforated peptic ulcer during Ramadan months (Group II), while the remaining 77 cases (89.54%) affected by this complication and underwent operation throughout the other 11 months of the lunar year (Group I), the monthly mean of perforated peptic ulcer requiring surgical intervention in Group I was 1.4 cases and 1.8 in Group II (Table 2 and Figure 2). With non-significant P-Value (1.14) Table (1): Number, sex, and percentage of the sample distributed according to age groups. Male Female Age groups/Sex Total number no % no % Less than 20 years 5 4 (80) 1 (20) 20- 29 years 18 14 (77.77) 4 (22.23) 30-39 years 23 19 (82.6) 4 (17.4) 40-49 years 10 9 (90) 1 (10) 50-59 years 14 11 (78.57) 3 (21.43) More than 60 years 16 12 (75) 4 (25) Total 86 69 (81.81) 17 (19.19) Twice the number of affected males was noticed in Group II in comparison to females within the same group, while the male-to-female ratio within Group I was 4.5:1 (Table 3). The mean age of Group I was 40.26 ± 18.49, while for Group II it was 48.11 ± 24.66, with insignificant P-value of 0.92. However we don’t have data for developing peptic ulcer complications during winter and cold weather period, but we compared the hot and long day times with milder hot and mildly shorter day times in our country in regards to the incidence of this complication, we observed that among group II, 5 (55.55%) cases developed perforated peptic ulcer and underwent surgery during hot seasons and long day fasting times (between mid of May and mid of June in our sample); the remaining 4 (44.45%) cases who developed this complication during shorter fasting time and less hot weather (Figure 3). Table (2): Distribution of the cases among the sample according to lunar years and months Lunar Month/ Lunar Year 1438 1439 1440 1441 1442 Total Muharram 1 2 1 1 1 6 Safar 0 1 1 1 1 4 Rabi al awwal 1 1 1 2 1 6 Rabi al thani 0 2 1 3 1 7 Jamad al awwal 2 2 3 1 1 9 Jamad al thani 1 0 2 2 1 6 Rajab 2 1 1 2 2 8 Sha'aban 2 1 2 3 1 9 Ramadan 2 1 3 2 1 9 Shawwal 1 2 2 3 2 10 Dhul qadah 1 1 2 2 1 7 Dhul hajja 1 0 1 1 2 5 Total 14 14 20 23 15 86 Table (3): Sex difference affected by peptic ulcer perforation within the sample. Sex Group I Group II Male 63 6 Female 14 3 Total 77 9 Discussion However, billions of Muslims in different countries are present with continued fasting, but surprisingly there has been a very small number of data reported in the literature regarding the correlation between peptic ulcer perforation and Ramadan fasting; mortality rates were almost similar between the groups of different studies. However, the mortality rate of perforated peptic ulcers was not the aim and detail of our study, so we did not evaluate its frequency, this estimated to be about 2.33% in some studies ( 7 , 9 , 18 – 20 ). However, hot summer days constitute the longest fasting durations (16 hours) in Iraq, and the shortest duration will be about 11 hours when Ramadan will coincide with the winter season. However we don’t have data for developing peptic ulcer complications during winter and cold weather period, but we compared the hot and long day times with milder hot and mildly shorter day times in our country in regards to the incidence of this complication, we observed that among group II, 5 (55.55%) cases developed perforated peptic ulcer and underwent surgery during hot seasons and long day fasting times (between mid of May and mid of June in our sample); the remaining 4 (44.45%) cases who developed this complication during shorter fasting time and less hot weather (Fig. 3), so we can conclude that more duration of day time and hotter weather have bad impact the development of this complication of peptic ulcer, however we have the limitation of small sample size in regards to this topic and it need further and broader studies to include all seasons of the year where Ramadan will coincide with them. There is no cut line between this weather and fasting duration days for perforated peptic ulcers. We can say that this complication may happen in other hot weathers and long daytimes beyond 15th August or before 15th May if Ramadan coincides with these periods. Our data was not containing the detail of the reason of perforated peptic ulcers, i.e. those patients underwent surgery either they had history of risk factors, diagnosed peptic ulcer, or they were in fasting state at the day of developing perforation or not, so we dealt with data only. Further studies of prospective ways of focusing on the Muslim patients who will fast during summer seasons of Ramadan with a larger sample size can better give the answer to the debate mentioned. Another study limitation is that, because of lack of full patient data and full history taking in regards to that point whether some patients who developed the complication during other months of the year (Group I) they were fasting or not, since some Muslims Fast during other months not related to Ramadan as part of Sunnah of prophet Mohammed (Peace be upon him) in addition to excluding the cases who presented during the days of Eid Al-Fitr from Group II in the study since only those cases who strictly developed the complication during Ramadan days in Group II . However, in general and in our study male patients were observed to be affected by perforated peptic ulcer more than female in Ramadan, but if we compare this complication in each sex separately between Ramadan and non-Ramadan months we will get different results, in our study among 17 female patients who underwent surgery for perforated peptic ulcer only 3 (17.65%) of them affected by the complication of their peptic ulcer during Ramadan meanwhile about 8.69% (6 out of 69) of male cases developed perforation of their peptic ulcers during this holly month (Table 3), this result is in contrast to other study done in Istanbul – Turkey ( 21 ) in which male predominates in the peptic ulcer perforation during Ramadan and they thought that the reason is that women are not allowed to be fasting throughout the days of their menstrual cycles, whereas fasting is obligatory for men in all days of Ramadan consecutively ( 9 ), different result is almost due to our small sample size, if we do other studies among other different hospitals and larger sample sizes the result may vary completely. In spite of the limitations mentioned in our study, we found slightly higher incidence of perforated peptic ulcer in Ramadan months (Table 2) but with insignificant P-Value (1.14), but the question of whether the patients with history and features of peptic ulcer disease can go on fasting or not needs a recommendation of some prophylactic measures to the faithful disciples of Ramadan fasting with peptic ulcer disease. However, Qurans, ayahs, Mohammed the prophet (peace be upon him), and Islamic laws allow people who are travelling, taking medications, and sick to not go on fasting in Ramadan, and they can substitute it in the next months or when they have the ability to do it, but people will prefer not to miss Ramadan fasting because of local customs, traditions, and religious authority figures. Again, further prospective study is required to get the answer to the effect of Ramadan on such complications, since Muslim patients believe that it is very necessary to fast during Holy Ramadan, and they do not want to miss this holy month if their diseases allow them and cause no impact on their health. Since our result showed slightly higher peptic ulcer perforation during Holly Ramadan (Table 2). These scientific results may lead people to become better informed regarding what prophylactic measures must be undertaken during fasting periods and which people should not fast. This can become effective when supported by educational seminars for the community based on scientific data present to convince the audience about the risks of imbalanced large meals two times a day, in addition to the necessity of prophylactic medication use for their diseases. Our study's weak point was that concomitant diseases could not be estimated deliberately, not only because of its retrospective way, but because of the lack of some valuable data in the file during the five years period of the study as well. Patient data in the Microsoft Access files was the most dependable reference of our study, recording only the basic information-related data, such as the triple name of patients, file number, age, gender, religion, admission and discharge dates, surgeon responsible, and final diagnosis, without recording the patients’ past medical, past surgical, drug, family, and socioeconomic histories, detailed surgical procedure, post-operative medications and follow-up, complications, and possible concomitant diseases. A similar but prospective study for collecting data for assessing a cycle of decades is preferred to prevent the loss of some valuable data. The lack of cross-examination of the patients’ history in their files regarding H. Pylori infection, alcohol drinking, and smoking was a disappointing point for our study, because all mentioned factors are regarded as risk factors for peptic ulcer perforation. Since our study has been done in one hospital receiving almost always patients from inside the city and surrounding towns with their rural areas, this point is again regarded as another limitation of our study because the result reflected only a part of a country, although 99% of inhabitants were Muslims, but may not well represent more than one billion Muslims present worldwide who follow the fasting ritual under various situations. ( 1 , 22 ) Conclusions The present study suggested that the occurrence of peptic ulcer perforation was relatively higher during Ramadan months in compare to other months of the year. Male predominates in the complication during Ramadan Recommendation Further studies of prospective ways of focusing on the Muslim patients who will fast during Ramadan, particularly during those Ramadan-coinciding summer seasons with larger sample sizes, can better give the answer to the debate of the relation of perforated peptic ulcers and Ramadan fasting. Declarations Conflict of interest: no conflicts of interest found in this study. Ethical declaration: This study was approved by the ethical committee at the Faculty of General Medicine, Koya University, Koya, Erbil, Iraq. Acknowledgements: Special thanks to Dr. Balen Salah Koyee, the manager of East Erbil Emergency Hospital and other administration employers for allowing and providing the hospital data to be used for this study. Consent for publication: Not applicable Competing interests: Not applicable Authors' contributions: Saman Taher Barzinjy: did all works including data collections, writing manuscript, data analysis, and submitting to the journal, he is the corresponding author also. Authors' information: Saman Taher Barzinjy, FICMS, FACS, Faculty of General Medicine, Koya University, KOY45, Kurdistan Region - F.R. Iraq, Erbil, IRQ. [email protected] Corresponding Author: Saman Taher Barzinjy, Department of Surgery, Faculty of General Medicine, Koya University, Koya KOY45, Kurdistan Region – F. R., Iraq. [email protected] , phone number: 009647504285892 Publication Declaration: The submitted manuscript is an original work with its merit, has not been previously published in whole or in part, and is not being considered for publication elsewhere. Authors Approval: The author has read the final manuscript, has approved the submission to the journal, and has accepted full responsibilities pertaining to the manuscript’s delivery and contents. Consent to participate declaration: The hospital manager was informed that the data will be used for scientific purposes, and verbal consent was obtained from him. Human Ethics and Consent to Participate declarations: Not applicable. Funding source: No financial support was received from any institution or individual for the study. Clinical trial number: this study was not clinical trial; only data used for the study, so clinical trial number is not applicable. Informed Consent: the hospital manager was informed that the data will be used for scientific purposes, and verbal consent was obtained from him. Data and material availability: data is available in Microsoft excel and Microsoft access sheets which taken from the patient data department of the hospital. 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LECA A, FORTESA L. Greater incidence of perforated peptic ulcers in the Ramadan period. Afr Fr Chir 1954; 12: 577-578. LAHBABI H. Significance of the frequency of perforated ulcer during the Ramadan. Maroc Med 1957; 36: 449-450. Kocakusak A. Does Ramadan fasting contribute to the increase of peptic ulcer perforations? Eur Rev Med Pharmacol Sci. 2017 Jan;21(1):150-154. PMID: 28121343. BHOGAL RH, ATHWAL R, DURKIN D, DEAKIN M, CHERUVU CN. Comparison between open and laparoscopic repair of perforated peptic ulcer disease. World J Surg 2008; 32: 2371-2374. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8719342","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":581720776,"identity":"0398826e-e938-4e84-951b-292f3f5f9a5e","order_by":0,"name":"Saman Taher Barzinjy","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0001-9351-6476","institution":"koya university","correspondingAuthor":true,"prefix":"","firstName":"Saman","middleName":"Taher","lastName":"Barzinjy","suffix":""}],"badges":[],"createdAt":"2026-01-28 10:32:43","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8719342/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8719342/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101439277,"identity":"06cc51ce-2e41-4553-9562-3110db8d70e1","added_by":"auto","created_at":"2026-01-29 16:42:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":13466,"visible":true,"origin":"","legend":"\u003cp\u003eSex distribution among the sample.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8719342/v1/b867e58a78550152cc3eea34.png"},{"id":101439278,"identity":"a3cfd07e-e379-4c08-ac41-c0134049e2a1","added_by":"auto","created_at":"2026-01-29 16:42:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":46096,"visible":true,"origin":"","legend":"\u003cp\u003enumber and percentage of the sample distributed according to months of the year.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8719342/v1/058478f3c5eb661b53b599d9.png"},{"id":101439279,"identity":"2ef768aa-7877-42e4-b412-2746622a530c","added_by":"auto","created_at":"2026-01-29 16:43:00","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":15616,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of the group II of the sample based on the included months\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8719342/v1/ea01c882ea4101642b953fd0.png"},{"id":101751445,"identity":"739b8e2d-85da-4881-92b4-518f3763b966","added_by":"auto","created_at":"2026-02-03 10:20:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":838704,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8719342/v1/a318417b-d9fa-4114-bc41-4d78c142673b.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eEffect of Ramadan Fasting Among Muslims on the Frequency of Perforated Peptic Ulcer, a Retrospective Study\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHowever, their reduction in the evidence in the last decades, perforation of peptic ulcers has still been an essential issue with its high frequency in emergency clinics and hospitals (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The 9th lunar month of the lunar calendar is Ramadan, which is the fasting month of the Muslim populations worldwide. This lunar calendar annually pushes the solar year of the Gregorian calendar by about 11 days earlier, since the Islamic year had been based on the lunar calendar, which contains 354 days. Fasting for long durations from Morning Prayer to evening prayer is technically difficult in some seasons, especially in Polar Regions and countries, where Muslims, in fact, will use local Arabic calendars, which unfortunately is not always approved by local religious Islamic representatives in those countries.\u003c/p\u003e \u003cp\u003eIn summary, fasting during the month of Ramadan is a total but intermittent fast throughout the whole daylight. In spite of medical treatment that has been broadly used in peptic ulcer diseases, peptic ulcer perforation still remains as a severe complication of the disease. because perforation of the alimentary tract organs may give rise to septic complications and even death, the purpose of the present study is based on the common correlation between Ramadan fasting and peptic ulcer perforation, which can be seen as an international issue because of migrations of large amount of Muslims populations to almost all countries throughout the last decades during our era of globalization. One of the five sine qua non of Islam is fasting throughout all the days of the holy Ramadan month. Fasting as a religious ritual from the perspective of the need for emergency surgical intervention because of perforated peptic ulcer has not been studied even in recent years. Many developments were awaited in that common complication of emergency applications; however, even conservative medical treatment has evolved for perforated peptic ulcers in selected cases. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eNowadays the prophylactic surgical intervention of peptic ulcer disease is abandoned because of the revolutions in the medications and successful conservative treatment options during the last decades; in spite of this, the frequency of perforated peptic ulcer is still high. This is the point of debate regarding whether Ramadan fasting is dangerous in a selected group of patients or not. Hence, some new visions regarding the relationship between fasting and perforated peptic ulcer in the era of conservative treatment are necessary, at least in a global era with a high frequency of vocations for tourism and large numbers of immigration. Because the Islamic fasting is a total fasting of both fluid and solid foods from the time of morning prayer to evening prayer time, this provides a unique physiological model, which is varies from experimental and voluntary fasting types. Analysis of the effect of fasting on perforated peptic ulcer will be complicated and challenging because Ramadan month will shift 11 days forward annually; this will lead to increased fasting periods in summers and decreased in winters.\u003c/p\u003e \u003cp\u003eThe avoidance of any liquid or food intake may last about 10\u0026ndash;19 hours depending on solar calendar and the season of countries. Moreover, the rate of fasting time change continues to raise more in the countries that are located in the North or South because fasting period is between sunrise and sunset. Unfortunately, while Ramadan coincides with winter months, fasting hours are the minimum, but while Ramadan is in summer, the fasting hours are longest. Since during Ramadan months, increasing the emergency presentation of some diseases has been well established, it has been a well-known fact that occurrences of duodenitis, duodenal ulcers, and perforated peptic ulcers as well were more common throughout Ramadan months (\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt has been estimated that fasting throughout Ramadan month will increase the gastric acidity over critical range, especially through the hours of the day time. The gastric acidity reaches its peak at the end hours of the fasting period. Hence, the rate of ulcer complications is statistically higher during Ramadan in comparison to other months. The frequency of the upper gastrointestinal bleeding is doubled, and perforation is estimated to be four times more than normal during those days (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). During fasting, pregnancy is also a factor resulting in perforated peptic ulcer (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Ketoacidosis or hypoglycemia is a well-known and studied complication of diabetes mellitus during the Ramadan month (\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEven infections have a role in increasing peptic ulcer perforation during Ramadan; this is the finding of 51 articles in a meta-analysis of a systematic review (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). It is shown that urinary tract infections are also more common throughout fasting time due to dehydration and inadequate fluid intake during the Ramadan month (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The changing profile of patients with peptic ulcer and perforated peptic ulcer because of successful use of antiulcer drugs, globalization, mass human migrations, concomitant diseases, and aging of the patients and populations, transforms some former diseases such as peptic ulcers, giving them new profiles. All these mentioned factors necessitate new studies for creating a novel vision for the physicians in our era.\u003c/p\u003e \u003cp\u003eThe aim of this retrospective study is to assess and find the effect of Ramadan fasting on peptic ulcer perforation in Erbil City, Kurdistan region, Iraq, which is one of the cities where most of the living populations are of the Islamic religion, and to find some clues of recommendations to inform and make patients aware about fasting in Ramadan, especially those complaining of gastrointestinal tract diseases.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003eThis retrospective study includes 86 patients who have been operated on by different general surgery specialists on the basis of the indication of perforated peptic ulcer in East Erbil Emergency Hospital between the period of October 2016 (Muharram of 1438 Hijri year) and August 2021 ( Muhrram of 1442 Hijri year). In the succeeding years, the start and the end of Ramadan shifted 11 days forward, so five Ramadan months included in the study, The 1st Ramadan included in this study was started on 26th May 2017, and the last day of Ramadan in the study was ended on 12th May 2021 but further cases beyond this period also included till August 2021 for the aim of including full 60 months of five Lunar years, so 5 months for each lunar months were included.\u003c/p\u003e \u003cp\u003ePatients were classified into two groups. Group I (No. 77) included the patients who had been operated during other months of the lunar years (Muharram, Safar, Rabi al-awwal, Rabi al-thani, Jamada al-awwal, Jamada al-thani, Rajab, Sha\u0026rsquo;aban, Shawwal, Dhul Qadah, and Dhul hijja) that was constitute 55 months, patients who underwent operation during the fasting month of Ramadan (the remaining 5 months) classified under the Group II (No. 9). The data was taken from a file of patients\u0026rsquo; data in the Microsoft Access version 2010 database in the data entry department of East Erbil emergency hospital.\u003c/p\u003e \u003cp\u003eThe cases were also classified into age groups of less than 20 years, 20\u0026ndash;29 years, 30\u0026ndash;39 years, 40\u0026ndash;49 years, 50\u0026ndash;59 years, and 60 and more.\u003c/p\u003e \u003cp\u003eThe longest day times in Iraq is between 15th May \u0026minus;\u0026thinsp;15th August, which will reach 14 hr. and more, meanwhile the shortest day time that will be 9 hr. and less is between 21st November and 21st February, these two ranges (each three months) calculated for observing the perforated peptic ulcer rate in long day time and hot weather period (most Ramadan months in this study were located within this long day time period, and the other days were also very close to this period).\u003c/p\u003e \u003cp\u003ePermission was taken from the related administrative persons in the hospital, and they were informed that the hospital data could be used for studies and scientific purposes in the future. The data base file contained patients data during the mentioned periods of the years, however some data was not clear and lost regarding age, gender, the exact diagnoses, admission and discharge times, all were excluded from the study, other religions of the patients such as Christian and Yazidi also excluded from the study since they have other religious views and they do not fast during Ramadan, the Microsoft access file contained the data about, name, file number, age, sex, religion, admission and discharge date, specialist responsible, and final diagnosis, surgical method, and mortality.\u003c/p\u003e \u003cp\u003eData entry and statistical analysis were done by the use of the Microsoft Excel program version 2010. P-values calculated by t-test.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe total number of cases were 86 cases, 69 (80.23%) of them were male and the remaining 17 (19.77%) were female (Figure 1), the age ranged between 11 \u0026ndash; 90 years with a mean and SD 41.08 \u0026plusmn; 18.40,age group of 20 \u0026ndash; 39 years old constitutes nearly half \u0026nbsp;(41 no, 47.67%) of the sample (33 male and 8 females), age group 60 years old and above came in the next frequency by 16 cases (18.6%) of the whole sample (12 male and 4 female), meanwhile least number reported among the group of less than 20 years old ( 4 male and 1 female), again among the age group of 20-39 years and \u0026nbsp; 60 years and above both male and female sex recorded highest incidence in compare to their sex among the other age groups (Table 1).\u003c/p\u003e\n\u003cp\u003eAmong the sample, 9 cases (10.46%) were found to develop perforated peptic ulcer during Ramadan months (Group II), while the remaining 77 cases (89.54%) affected by this complication and underwent operation throughout the other 11 months of the lunar year (Group I), the monthly mean of perforated peptic ulcer requiring surgical intervention in Group I was 1.4 cases and 1.8 in Group II (Table 2 and Figure 2). With non-significant P-Value (1.14)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (1):\u0026nbsp;\u003c/strong\u003eNumber, sex, and percentage of the sample distributed according to age groups.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"543\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.0441%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8309%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.6544%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; Male \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4706%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;Female\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.0441%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge groups/Sex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8309%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal number\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.6544%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eno \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4706%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eno \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.0441%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLess than 20 years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8309%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.6544%;\"\u003e\n \u003cp\u003e4 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; (80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4706%;\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.0441%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e20- 29 years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8309%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.6544%;\"\u003e\n \u003cp\u003e14 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; (77.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4706%;\"\u003e\n \u003cp\u003e4 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; (22.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.0441%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e30-39 years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8309%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.6544%;\"\u003e\n \u003cp\u003e19 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;(82.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4706%;\"\u003e\n \u003cp\u003e4 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;(17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.0441%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e40-49 years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8309%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.6544%;\"\u003e\n \u003cp\u003e9 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4706%;\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;(10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.0441%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e50-59 years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8309%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.6544%;\"\u003e\n \u003cp\u003e11 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; (78.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4706%;\"\u003e\n \u003cp\u003e3 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;(21.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.0441%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMore than 60 years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8309%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.6544%;\"\u003e\n \u003cp\u003e12 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;(75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4706%;\"\u003e\n \u003cp\u003e4 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.0441%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8309%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.6544%;\"\u003e\n \u003cp\u003e69 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; (81.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4706%;\"\u003e\n \u003cp\u003e17 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; (19.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTwice the number of affected males was noticed in Group II in comparison to females within the same group, while the male-to-female ratio within Group I was 4.5:1 (Table 3). The mean age of Group I was 40.26 \u0026plusmn; 18.49, while for Group II it was 48.11 \u0026plusmn; 24.66,\u0026nbsp;with insignificant P-value of 0.92.\u003c/p\u003e\n\u003cp\u003eHowever we don\u0026rsquo;t have data for developing peptic ulcer complications during winter and cold weather period, but we compared the hot and long day times with milder hot and mildly shorter day times in our country in regards to the incidence of this complication, we observed that among group II, 5 (55.55%) cases developed perforated peptic ulcer and underwent surgery during hot seasons and long day fasting times (between mid of May and mid of June in our sample); the remaining 4 (44.45%) cases who developed this complication during shorter fasting time and less hot weather (Figure 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (2):\u0026nbsp;\u003c/strong\u003eDistribution of the cases among the sample according to lunar years and months\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"549\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38.3636%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003eLunar Month/ Lunar Year\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.8182%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e1438\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.1818%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e1439\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e1440\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e1441\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9.27273%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e1442\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.90909%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003eTotal\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38.3636%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMuharram\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.8182%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.1818%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9.27273%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.90909%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38.3636%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSafar\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.8182%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.1818%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9.27273%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.90909%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38.3636%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRabi al awwal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.8182%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.1818%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9.27273%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.90909%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38.3636%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRabi al thani\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.8182%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.1818%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9.27273%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.90909%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38.3636%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eJamad al awwal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.8182%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.1818%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9.27273%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.90909%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38.3636%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eJamad al thani\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.8182%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.1818%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9.27273%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.90909%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38.3636%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRajab\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.8182%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.1818%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9.27273%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.90909%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38.3636%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSha\u0026apos;aban\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.8182%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.1818%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9.27273%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.90909%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38.3636%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRamadan\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.8182%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.1818%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9.27273%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.90909%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38.3636%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eShawwal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.8182%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.1818%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9.27273%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.90909%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38.3636%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDhul qadah\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.8182%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.1818%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9.27273%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.90909%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38.3636%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDhul hajja\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.8182%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.1818%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9.27273%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.90909%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38.3636%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.8182%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.1818%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.7273%;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9.27273%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.90909%;\"\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable (3):\u003c/strong\u003e Sex difference affected by peptic ulcer perforation within the sample.\u003c/p\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"489\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28.5714%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 34.0816%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup I\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 37.3469%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup II\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28.5714%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 34.0816%;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 37.3469%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28.5714%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 34.0816%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 37.3469%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28.5714%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 34.0816%;\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 37.3469%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eHowever, billions of Muslims in different countries are present with continued fasting, but surprisingly there has been a very small number of data reported in the literature regarding the correlation between peptic ulcer perforation and Ramadan fasting; mortality rates were almost similar between the groups of different studies. However, the mortality rate of perforated peptic ulcers was not the aim and detail of our study, so we did not evaluate its frequency, this estimated to be about 2.33% in some studies (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, hot summer days constitute the longest fasting durations (16 hours) in Iraq, and the shortest duration will be about 11 hours when Ramadan will coincide with the winter season. However we don\u0026rsquo;t have data for developing peptic ulcer complications during winter and cold weather period, but we compared the hot and long day times with milder hot and mildly shorter day times in our country in regards to the incidence of this complication, we observed that among group II, 5 (55.55%) cases developed perforated peptic ulcer and underwent surgery during hot seasons and long day fasting times (between mid of May and mid of June in our sample); the remaining 4 (44.45%) cases who developed this complication during shorter fasting time and less hot weather (Fig.\u0026nbsp;3), so we can conclude that more duration of day time and hotter weather have bad impact the development of this complication of peptic ulcer, however we have the limitation of small sample size in regards to this topic and it need further and broader studies to include all seasons of the year where Ramadan will coincide with them.\u003c/p\u003e \u003cp\u003eThere is no cut line between this weather and fasting duration days for perforated peptic ulcers. We can say that this complication may happen in other hot weathers and long daytimes beyond 15th August or before 15th May if Ramadan coincides with these periods. Our data was not containing the detail of the reason of perforated peptic ulcers, i.e. those patients underwent surgery either they had history of risk factors, diagnosed peptic ulcer, or they were in fasting state at the day of developing perforation or not, so we dealt with data only. Further studies of prospective ways of focusing on the Muslim patients who will fast during summer seasons of Ramadan with a larger sample size can better give the answer to the debate mentioned. Another study limitation is that, because of lack of full patient data and full history taking in regards to that point whether some patients who developed the complication during other months of the year (Group I) they were fasting or not, since some Muslims Fast during other months not related to Ramadan as part of Sunnah of prophet Mohammed (Peace be upon him) in addition to excluding the cases who presented during the days of Eid Al-Fitr from Group II in the study since only those cases who strictly developed the complication during Ramadan days in Group II .\u003c/p\u003e \u003cp\u003eHowever, in general and in our study male patients were observed to be affected by perforated peptic ulcer more than female in Ramadan, but if we compare this complication in each sex separately between Ramadan and non-Ramadan months we will get different results, in our study among 17 female patients who underwent surgery for perforated peptic ulcer only 3 (17.65%) of them affected by the complication of their peptic ulcer during Ramadan meanwhile about 8.69% (6 out of 69) of male cases developed perforation of their peptic ulcers during this holly month (Table\u0026nbsp;3), this result is in contrast to other study done in Istanbul \u0026ndash; Turkey (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) in which male predominates in the peptic ulcer perforation during Ramadan and they thought that the reason is that women are not allowed to be fasting throughout the days of their menstrual cycles, whereas fasting is obligatory for men in all days of Ramadan consecutively (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), different result is almost due to our small sample size, if we do other studies among other different hospitals and larger sample sizes the result may vary completely.\u003c/p\u003e \u003cp\u003eIn spite of the limitations mentioned in our study, we found slightly higher incidence of perforated peptic ulcer in Ramadan months (Table\u0026nbsp;2) but with insignificant P-Value (1.14), but the question of whether the patients with history and features of peptic ulcer disease can go on fasting or not needs a recommendation of some prophylactic measures to the faithful disciples of Ramadan fasting with peptic ulcer disease. However, Qurans, ayahs, Mohammed the prophet (peace be upon him), and Islamic laws allow people who are travelling, taking medications, and sick to not go on fasting in Ramadan, and they can substitute it in the next months or when they have the ability to do it, but people will prefer not to miss Ramadan fasting because of local customs, traditions, and religious authority figures. Again, further prospective study is required to get the answer to the effect of Ramadan on such complications, since Muslim patients believe that it is very necessary to fast during Holy Ramadan, and they do not want to miss this holy month if their diseases allow them and cause no impact on their health.\u003c/p\u003e \u003cp\u003eSince our result showed slightly higher peptic ulcer perforation during Holly Ramadan (Table\u0026nbsp;2). These scientific results may lead people to become better informed regarding what prophylactic measures must be undertaken during fasting periods and which people should not fast. This can become effective when supported by educational seminars for the community based on scientific data present to convince the audience about the risks of imbalanced large meals two times a day, in addition to the necessity of prophylactic medication use for their diseases. Our study's weak point was that concomitant diseases could not be estimated deliberately, not only because of its retrospective way, but because of the lack of some valuable data in the file during the five years period of the study as well. Patient data in the Microsoft Access files was the most dependable reference of our study, recording only the basic information-related data, such as the triple name of patients, file number, age, gender, religion, admission and discharge dates, surgeon responsible, and final diagnosis, without recording the patients\u0026rsquo; past medical, past surgical, drug, family, and socioeconomic histories, detailed surgical procedure, post-operative medications and follow-up, complications, and possible concomitant diseases. A similar but prospective study for collecting data for assessing a cycle of decades is preferred to prevent the loss of some valuable data.\u003c/p\u003e \u003cp\u003eThe lack of cross-examination of the patients\u0026rsquo; history in their files regarding H. Pylori infection, alcohol drinking, and smoking was a disappointing point for our study, because all mentioned factors are regarded as risk factors for peptic ulcer perforation. Since our study has been done in one hospital receiving almost always patients from inside the city and surrounding towns with their rural areas, this point is again regarded as another limitation of our study because the result reflected only a part of a country, although 99% of inhabitants were Muslims, but may not well represent more than one billion Muslims present worldwide who follow the fasting ritual under various situations. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe present study suggested that the occurrence of peptic ulcer perforation was relatively higher during Ramadan months in compare to other months of the year. Male predominates in the complication during Ramadan\u003c/p\u003e\n\u003ch3\u003eRecommendation\u003c/h3\u003e\n\u003cp\u003eFurther studies of prospective ways of focusing on the Muslim patients who will fast during Ramadan, particularly during those Ramadan-coinciding summer seasons with larger sample sizes, can better give the answer to the debate of the relation of perforated peptic ulcers and Ramadan fasting.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest:\u003c/strong\u003e no conflicts of interest found in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical declaration:\u003c/strong\u003e This study was approved by the ethical committee at the Faculty of General Medicine, Koya University, Koya, Erbil, Iraq.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e Special thanks to Dr. Balen Salah Koyee, the manager of East Erbil Emergency Hospital and other administration employers for allowing and providing the hospital data to be used for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e Saman Taher Barzinjy: did all works including data collections, writing manuscript, data analysis, and submitting to the journal, he is the corresponding author also.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information:\u003c/strong\u003e\u0026nbsp; Saman Taher Barzinjy, FICMS, FACS, Faculty of General Medicine, Koya University, KOY45, Kurdistan Region - F.R. Iraq, Erbil, IRQ. \u0026nbsp;[email protected]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding Author:\u0026nbsp;\u003c/strong\u003eSaman Taher Barzinjy, Department of Surgery, Faculty of General Medicine, Koya University, Koya KOY45, Kurdistan Region \u0026ndash; F. R., Iraq. \u0026nbsp;[email protected] , phone number: 009647504285892\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePublication Declaration:\u0026nbsp;\u003c/strong\u003eThe submitted manuscript is an original work with its merit, has not been previously published in whole or in part, and is not being considered for publication elsewhere.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Approval:\u003c/strong\u003e\u0026nbsp; The author has read the final manuscript, has approved the submission to the journal, and has accepted full responsibilities pertaining to the manuscript\u0026rsquo;s delivery and contents.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate declaration:\u003c/strong\u003e The hospital manager was informed that the data will be used for scientific purposes, and verbal consent was obtained from him.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding source:\u003c/strong\u003e No financial support was received from any institution or individual for the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number: this study was not clinical trial; only data used for the study, so clinical trial number is not applicable.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent:\u003c/strong\u003e the hospital manager was informed that the data will be used for scientific purposes, and verbal consent was obtained from him.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData and material availability:\u003c/strong\u003e data is available in Microsoft excel and Microsoft access sheets which taken from the patient data department of the hospital.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSUN JY, SUN DJ, LI XJ, JIAO K, ZHAI ZW. Laparoscopic treatment experience of severe acute pancreatitis complicated by peptic ulcer perforation. Eur Rev Med Pharmacol Sci 2016; 20: 285-290.\u003c/li\u003e\n\u003cli\u003eIANIRO G, FRANCESCHI F, BIBB\u0026Ograve; S, GASBARRINI A. Omega-3 fatty acids: a novel resort against gastrointestinal injury. Eur Rev Med Pharmacol Sci 2014; 18: 3086-3090.\u003c/li\u003e\n\u003cli\u003eSONGNE B, JEAN F, FOULATIER O, KHALIL A, SCOTTE M. Nonoperative treatment for perforated peptic ulcer: results of a prospective study. Ann Chir 2004; 129: 578-582.\u003c/li\u003e\n\u003cli\u003eGOKAKIN AK, KURT A, AKGOL G, KARAKUS BC, ATABEYM, KOYUNCU A, TOPCU O, GOREN E. Effects of Ramadan fasting on peptic ulcer disease as diagnosed by upper gastrointestinal endoscopy. Arab J Gastroenterol 2012; 13: 180-183.\u003c/li\u003e\n\u003cli\u003eHERRAG M, LAHMITI S, YAZIDI AA. Ramadan: a different side of the emergencies? Afr Health Sci 2010; 10: 215-216.\u003c/li\u003e\n\u003cli\u003eMALIK GM, MUBARIK M, JEELANI G, TAJAMUL H, KADLASA, LONE BA, KHAN MD. Endoscopic evaluation of peptic ulcer disease during Ramadan fasting. Diagn Ther Endosc 1996; 2: 219-221.\u003c/li\u003e\n\u003cli\u003eTORAB FC, AMER M, ABU-ZIDAN FM, BRANICKI FJ. Perforated peptic ulcer: different ethnic, climatic, and fasting risk factors for morbidity in the Al Ain medical district, United Arab Emirates. Asian J Surg 2009; 32: 95-101.\u003c/li\u003e\n\u003cli\u003eHOSSEINI-ASL K, RAFIEIAN-KOPAEI M. Can patients with active duodenal ulcers fast during Ramadan? Am J Gastroenterol 2002; 97: 2471-2472.\u003c/li\u003e\n\u003cli\u003eG\u0026Ouml;KAKIN AK, KURT A, ATABEY M, KOYUNCU A, TOP\u0026Ccedil;UO, AYDIN C, SEN M, AKG\u0026Ouml;L G. The impact of Ramadan on peptic ulcer perforation. Ulus Travma Acil Cerrahi Derg 2012; 18: 339-343.\u003c/li\u003e\n\u003cli\u003eBDIOUI F, MELKI W, BEN MANSOUR W, LOGHMARI H, HELLARA O, BEN CHAABANE N, SAFFAR H. Duodenal ulcer disease and Ramadan. Presse Med 2012; 41: 807-812.\u003c/li\u003e\n\u003cli\u003eGALI BM, IBRAHIM AG, CHAMA CM, MSHELIA HB, ABUBAKAR A, TAKAI IU, BWALA S. Perforated peptic ulcer (PPUin pregnancy during Ramadan fasting. Niger J Med 2011; 20: 292-293.\u003c/li\u003e\n\u003cli\u003eABBAS Z. Gastrointestinal health in Ramadan with special reference to diabetes. J Pak Med Assoc 2015; 65: 68-71.\u003c/li\u003e\n\u003cli\u003eAZIZI F. Islamic fasting and health. Ann Nutr Metab 2010; 56: 273-282.\u003c/li\u003e\n\u003cli\u003eBARUT I, TARHAN OR, CERCI C, KARAGUZEL N, AKDENIZ Y, BULBUL M. Prognostic factors of peptic ulcer perforation. Saudi Med J 2005; 26: 1255-1259.\u003c/li\u003e\n\u003cli\u003eBENAJI B, MOUNIB N, ROKY R, AADIL N, HOUTI IE, MOUSSAMIH S, MALIKI S, GRESSIER B, EL GHOMARI H. Diabetes and Ramadan: review of the literature. Diabetes Res Clin Pract 2006; 73: 117-125.\u003c/li\u003e\n\u003cli\u003eBRAGAZZI NL, BRIKI W, KHABBACHE H, RAMMOUZ I, MNADLA S, DEMAJ T, ZOUHIR M. Ramadan fasting and infectious diseases: a systematic review. J Infect Dev Ctries 2015; 9: 1186-1194.\u003c/li\u003e\n\u003cli\u003eSALAHUDDIN N. How to avoid infections in Ramadan, especially urinary tract infections. J Pak Med Assoc 2015; 65: 65-67.\u003c/li\u003e\n\u003cli\u003eCHALYA PL, MABULA JB, KOY M, MCHEMBE MD, JAKA HM, KABANGILA R, CHANDIKA AB, GILYOMA JM. Clinical profile and outcome of surgical treatment of perforated peptic ulcers in northwestern Tanzania: a tertiary hospital experience. World J Emerg Surg 2011; 6: 31.\u003c/li\u003e\n\u003cli\u003eLECA A, FORTESA L. Greater incidence of perforated peptic ulcers in the Ramadan period. Afr Fr Chir 1954; 12: 577-578.\u003c/li\u003e\n\u003cli\u003eLAHBABI H. Significance of the frequency of perforated ulcer during the Ramadan. Maroc Med 1957; 36: 449-450.\u003c/li\u003e\n\u003cli\u003eKocakusak A. Does Ramadan fasting contribute to the increase of peptic ulcer perforations? Eur Rev Med Pharmacol Sci. 2017 Jan;21(1):150-154. PMID: 28121343.\u003c/li\u003e\n\u003cli\u003eBHOGAL RH, ATHWAL R, DURKIN D, DEAKIN M, CHERUVU CN. Comparison between open and laparoscopic repair of perforated peptic ulcer disease. World J Surg 2008; 32: 2371-2374.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Koya University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Ramadan fasting and peptic ulcer, perforated peptic ulcer and Ramadan fasting, Ramadan effect on peptic ulcer perforation","lastPublishedDoi":"10.21203/rs.3.rs-8719342/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8719342/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e peptic ulcer is a chronic lesion that occurs in any portion of GIT (usually stomach), it is exposed to the aggressive action of acid peptic juice, this disease has been broadly treated medically, peptic ulcer has numbers of complications still perforation is one of the commonest and severe form of complications, if happened it should be treated as soon as possible.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e To assess the effect of fasting among Islamic people during Ramadan month on peptic ulcer perforation in Erbil province.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients and Methods:\u003c/strong\u003e a retrospective study of 86 Patients who underwent operation for perforated peptic ulcers (gastric and duodenal) in an emergency Hospital of Erbil City – Kurdistan Region - Iraq between the period of October 2016 and August 2021 were coincide the period between (60 lunar months) were analyzed. Patients divided into two groups. Group I (No. 77) included those who were underwent operation throughout other months of the years except the Ramadan (fasting month) while Group II (No.9) constituted of those patients who were underwent operation throughout the Ramadan (fasting month).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e No statistically significant difference in the mean ages between the groups (40.26 vs. 48.11 years) observed. The mean monthly number of surgical intervention rates was slightly higher in Ramadan months, generally male patients are predominating in peptic ulcer perforation during Ramadan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Occurrence of peptic ulcer perforation was relatively higher during Ramadan months, with male predominance.\u003c/p\u003e","manuscriptTitle":"Effect of Ramadan Fasting Among Muslims on the Frequency of Perforated Peptic Ulcer, a Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-29 16:42:50","doi":"10.21203/rs.3.rs-8719342/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7b555c5b-9fb3-440d-96f4-bf756abd335e","owner":[],"postedDate":"January 29th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":61960221,"name":"General Surgery"}],"tags":[],"updatedAt":"2026-03-30T20:39:20+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-29 16:42:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8719342","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8719342","identity":"rs-8719342","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}