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Effect of Ramadan on surgical emergencies

2004; Elsevier BV; Volume: 44; Issue: 3 Linguagem: Inglês

10.1016/j.annemergmed.2004.03.043

1097-6760

Erdal Göçmen, Mahmut Koç, Mesut Tez, Ömer Yoldaş, Aydin Bilgin, Mehmet Keşkek,

Religion, Spirituality, and Psychology

To the Editor:Ramadan is the holy month in Islamic religion, during which adult Muslims are required to comply with religious obligations every year. Ramadan occurs in the ninth month of the lunar calendar, lasting between 29 and 30 days. The lunar calendar does not correspond to the Gregorian calendar; therefore, Ramadan occurs nearly 11 to 12 days earlier each successive year. During the Ramadan month, practicing Muslims not only fast, they also abstain from any kind of medication, smoking, sexual intercourse, and alcohol intake from sunrise to sunset.1.Kadri N. Tilane A. El Batal M. et al.Irritability during the month of Ramadan.Psychosom Med. 2000; 62: 280-285Crossref PubMed Scopus (79) Google Scholar Most people also continue to abstain from alcohol intake after sunset until Ramadan month is over.Daily routines are markedly changed during Ramadan. Although people fast during the daytime, they supply their bodies' needs between sunset and sunrise. Thus, the obligation to eat and smoke only during the night has been shown to change the rhythm of life, including sleep and eating schedules and alternation of working and resting times. As a result of withdrawal during the daytime and massive intake after sunset, people have been shown to have more irritability and anxiety during Ramadan.1.Kadri N. Tilane A. El Batal M. et al.Irritability during the month of Ramadan.Psychosom Med. 2000; 62: 280-285Crossref PubMed Scopus (79) Google Scholar Although fasting people have been shown to have an increased rate of peptic ulcer complications and disorders of platelet aggregation, no increase has been detected in stroke incidence, cardiovascular disorders, and metabolic derangements such as diabetes mellitus.2.Donderici O. Temizhan A. Kucukbas T. et al.Effect of Ramadan on peptic ulcer complications.Scand J Gastroenterol. 1994; 29: 603-606Crossref PubMed Scopus (42) Google Scholar, 3.Akhan G. Kutluhan S. Koyuncuoglu H.R. Is there any change of stroke incidence during Ramadan?.Acta Neurol Scand. 2000; 101: 259-261Crossref PubMed Scopus (54) Google Scholar, 4.Temizhan A. Donderici O. Oguz D. et al.Is there any effect of Ramadan fasting on acute coronary heart disease events?.Int J Cardiol. 1999; 70: 149-153Abstract Full Text Full Text PDF PubMed Scopus (73) Google ScholarThe aim of this study was to investigate whether patient profiles change in surgical emergency units during Ramadan.Time periods corresponding to the month of Ramadan in the Gregorian calendar were established, because the lunar calendar is 11 to 12 days shorter than the solar year. Records of patients who were operated on in the surgical emergency unit in Ankara Numune Hospital 1 month before, during, and 1 month after Ramadan were evaluated retrospectively between 1999 and 2003.The intraoperative diagnoses of patients were coded and analyzed using SPSS software (SPSS, Inc., Chicago, IL). Testing for differences between groups was performed using χ2 analysis.Table (Göçmen et al)Distribution of patients during the study period.Pre-intraoperative DiagnosisBefore Ramadan, No. (%) [95% CI]During Ramadan, No. (%) [95% CI]After Ramadan, No. (%) [95% CI]Peptic ulcer perforation38 (7.7) [1.05–1.10]78 (16.0) [1.12–1.19]34 (7.9) [1.05–1.10]Acute mesenteric ischemia8 (1.6) [1.00–1.02]18 (3.7) [1.02–1.05]6 (1.4) [1.00–1.02]Penetrating injuries54 (11.0) [1.08–1.13]24 (4.9) [1.02–1.06]34 (7.9) [1.06–1.10]Traffic accidents40 (8.1) [1.05–1.10]31 (6.3) [1.04–1.08]28 (6.5) [1.04–1.08]Acute appendicitis171 (34.8) [1.30–1.39]188 (38.4) [1.34–1.43]174 (43.0) [1.38–1.47]Acute cholecystitis45 (9.2) [1.06–1.11]38 (7.8) [1.05–1.10]39 (9.1) [1.06–1.11]Incarcerated hernia50 (10.2) [1.07–1.12]34 (7.0) [1.04–1.09]29 (6.8) [1.04–1.09]Other85 (17.3) [1.13–1.20]78 (15.9) [1.12–1.19]84 (19.6) [1.15–1.23]Total491489428CI, Confidence interval. Open table in a new tab More than 99% of the population in Turkey is Muslim, and at least 70% of Muslims fast regularly during the month of Ramadan.4.Temizhan A. Donderici O. Oguz D. et al.Is there any effect of Ramadan fasting on acute coronary heart disease events?.Int J Cardiol. 1999; 70: 149-153Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar In this first retrospective review on all surgical emergencies in relation to fasting during Ramadan, we found significant differences in the ratio of peptic ulcer perforation, acute mesenteric ischemia, and violence-induced penetrating injuries. Previous studies documented an association between Ramadan fasting and hematologic, biochemical, hormonal, mood, and alertness changes.1.Kadri N. Tilane A. El Batal M. et al.Irritability during the month of Ramadan.Psychosom Med. 2000; 62: 280-285Crossref PubMed Scopus (79) Google ScholarA number of studies revealed that a type of partial hunger during Ramadan increases peptic ulcer complications as a result of changes in various physiologic parameters, including gastric acid secretion and gastrointestinal motility.2.Donderici O. Temizhan A. Kucukbas T. et al.Effect of Ramadan on peptic ulcer complications.Scand J Gastroenterol. 1994; 29: 603-606Crossref PubMed Scopus (42) Google Scholar We found that peptic ulcer perforations nearly doubled during Ramadan compared with previous and subsequent months. Recently, Hosseini-asl and Rafieian-Kopaei5.Hosseini-asl K. Rafieian-kopaei M. Can patients with active duodenal ulcer fast Ramadan?.Am J Gastroenterol. 2002; 97: 2471-2472Crossref PubMed Scopus (30) Google Scholar reported that people could fast even with an active duodenal ulcer as long as they took proton pump inhibitors during Ramadan. Because our study is retrospective, we don't know whether the patients presenting with peptic ulcer perforations in this study had a history of peptic ulcer disease and took anti-ulcer medication during Ramadan. Therefore, it is difficult to suggest on the basis of this study's findings that patients with a history of peptic ulcer disease not fast during Ramadan; however, it is clear that there is an increased incidence of peptic ulcer complications during Ramadan.Previous investigators have found no variation in the incidence of stroke, acute coronary heart disease, and congestive heart failure, all of which are related to physiologic changes in the circulatory system, in relation to Ramadan.3.Akhan G. Kutluhan S. Koyuncuoglu H.R. Is there any change of stroke incidence during Ramadan?.Acta Neurol Scand. 2000; 101: 259-261Crossref PubMed Scopus (54) Google Scholar, 4.Temizhan A. Donderici O. Oguz D. et al.Is there any effect of Ramadan fasting on acute coronary heart disease events?.Int J Cardiol. 1999; 70: 149-153Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar However, an interesting and surprising finding of the current study was the more than twice increased ratio of acute mesenteric ischemia during Ramadan; all of these mesenteric ischemia patients admitted during Ramadan were elderly. As a result of fluid restriction during the daytime, people are undoubtedly experiencing dehydration during Ramadan fasting. Eating schedules also change during Ramadan, as previously mentioned, and after sunset there is massive food intake, which results in rapid intestinal absorption of these digested elements. We think that both dehydration and rapid intestinal absorption of food stuff may increase blood viscosity and cause vascular obstruction which, in turn, may result in mesenteric ischemia.A final result of this study was the significantly decreased ratio of violence-induced penetrating injuries. Kadri et al1.Kadri N. Tilane A. El Batal M. et al.Irritability during the month of Ramadan.Psychosom Med. 2000; 62: 280-285Crossref PubMed Scopus (79) Google Scholar reported increased irritability and anxiety during Ramadan. However, broad-based market research conducted throughout Turkey during Ramadan has shown that alcohol sales and consumption decrease noticeably during Ramadan. Consequently, decreased alcohol consumption results in a decreased ratio of fights, loss of self-control, and violence, all of which result in a decreased ratio of violence-induced penetrating injuries.In conclusion, our findings indicate that physiologic and behavioral changes during Ramadan may alter patient profiles in a surgical emergency unit. To the Editor: Ramadan is the holy month in Islamic religion, during which adult Muslims are required to comply with religious obligations every year. Ramadan occurs in the ninth month of the lunar calendar, lasting between 29 and 30 days. The lunar calendar does not correspond to the Gregorian calendar; therefore, Ramadan occurs nearly 11 to 12 days earlier each successive year. During the Ramadan month, practicing Muslims not only fast, they also abstain from any kind of medication, smoking, sexual intercourse, and alcohol intake from sunrise to sunset.1.Kadri N. Tilane A. El Batal M. et al.Irritability during the month of Ramadan.Psychosom Med. 2000; 62: 280-285Crossref PubMed Scopus (79) Google Scholar Most people also continue to abstain from alcohol intake after sunset until Ramadan month is over. Daily routines are markedly changed during Ramadan. Although people fast during the daytime, they supply their bodies' needs between sunset and sunrise. Thus, the obligation to eat and smoke only during the night has been shown to change the rhythm of life, including sleep and eating schedules and alternation of working and resting times. As a result of withdrawal during the daytime and massive intake after sunset, people have been shown to have more irritability and anxiety during Ramadan.1.Kadri N. Tilane A. El Batal M. et al.Irritability during the month of Ramadan.Psychosom Med. 2000; 62: 280-285Crossref PubMed Scopus (79) Google Scholar Although fasting people have been shown to have an increased rate of peptic ulcer complications and disorders of platelet aggregation, no increase has been detected in stroke incidence, cardiovascular disorders, and metabolic derangements such as diabetes mellitus.2.Donderici O. Temizhan A. Kucukbas T. et al.Effect of Ramadan on peptic ulcer complications.Scand J Gastroenterol. 1994; 29: 603-606Crossref PubMed Scopus (42) Google Scholar, 3.Akhan G. Kutluhan S. Koyuncuoglu H.R. Is there any change of stroke incidence during Ramadan?.Acta Neurol Scand. 2000; 101: 259-261Crossref PubMed Scopus (54) Google Scholar, 4.Temizhan A. Donderici O. Oguz D. et al.Is there any effect of Ramadan fasting on acute coronary heart disease events?.Int J Cardiol. 1999; 70: 149-153Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar The aim of this study was to investigate whether patient profiles change in surgical emergency units during Ramadan. Time periods corresponding to the month of Ramadan in the Gregorian calendar were established, because the lunar calendar is 11 to 12 days shorter than the solar year. Records of patients who were operated on in the surgical emergency unit in Ankara Numune Hospital 1 month before, during, and 1 month after Ramadan were evaluated retrospectively between 1999 and 2003. The intraoperative diagnoses of patients were coded and analyzed using SPSS software (SPSS, Inc., Chicago, IL). Testing for differences between groups was performed using χ2 analysis. CI, Confidence interval. More than 99% of the population in Turkey is Muslim, and at least 70% of Muslims fast regularly during the month of Ramadan.4.Temizhan A. Donderici O. Oguz D. et al.Is there any effect of Ramadan fasting on acute coronary heart disease events?.Int J Cardiol. 1999; 70: 149-153Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar In this first retrospective review on all surgical emergencies in relation to fasting during Ramadan, we found significant differences in the ratio of peptic ulcer perforation, acute mesenteric ischemia, and violence-induced penetrating injuries. Previous studies documented an association between Ramadan fasting and hematologic, biochemical, hormonal, mood, and alertness changes.1.Kadri N. Tilane A. El Batal M. et al.Irritability during the month of Ramadan.Psychosom Med. 2000; 62: 280-285Crossref PubMed Scopus (79) Google Scholar A number of studies revealed that a type of partial hunger during Ramadan increases peptic ulcer complications as a result of changes in various physiologic parameters, including gastric acid secretion and gastrointestinal motility.2.Donderici O. Temizhan A. Kucukbas T. et al.Effect of Ramadan on peptic ulcer complications.Scand J Gastroenterol. 1994; 29: 603-606Crossref PubMed Scopus (42) Google Scholar We found that peptic ulcer perforations nearly doubled during Ramadan compared with previous and subsequent months. Recently, Hosseini-asl and Rafieian-Kopaei5.Hosseini-asl K. Rafieian-kopaei M. Can patients with active duodenal ulcer fast Ramadan?.Am J Gastroenterol. 2002; 97: 2471-2472Crossref PubMed Scopus (30) Google Scholar reported that people could fast even with an active duodenal ulcer as long as they took proton pump inhibitors during Ramadan. Because our study is retrospective, we don't know whether the patients presenting with peptic ulcer perforations in this study had a history of peptic ulcer disease and took anti-ulcer medication during Ramadan. Therefore, it is difficult to suggest on the basis of this study's findings that patients with a history of peptic ulcer disease not fast during Ramadan; however, it is clear that there is an increased incidence of peptic ulcer complications during Ramadan. Previous investigators have found no variation in the incidence of stroke, acute coronary heart disease, and congestive heart failure, all of which are related to physiologic changes in the circulatory system, in relation to Ramadan.3.Akhan G. Kutluhan S. Koyuncuoglu H.R. Is there any change of stroke incidence during Ramadan?.Acta Neurol Scand. 2000; 101: 259-261Crossref PubMed Scopus (54) Google Scholar, 4.Temizhan A. Donderici O. Oguz D. et al.Is there any effect of Ramadan fasting on acute coronary heart disease events?.Int J Cardiol. 1999; 70: 149-153Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar However, an interesting and surprising finding of the current study was the more than twice increased ratio of acute mesenteric ischemia during Ramadan; all of these mesenteric ischemia patients admitted during Ramadan were elderly. As a result of fluid restriction during the daytime, people are undoubtedly experiencing dehydration during Ramadan fasting. Eating schedules also change during Ramadan, as previously mentioned, and after sunset there is massive food intake, which results in rapid intestinal absorption of these digested elements. We think that both dehydration and rapid intestinal absorption of food stuff may increase blood viscosity and cause vascular obstruction which, in turn, may result in mesenteric ischemia. A final result of this study was the significantly decreased ratio of violence-induced penetrating injuries. Kadri et al1.Kadri N. Tilane A. El Batal M. et al.Irritability during the month of Ramadan.Psychosom Med. 2000; 62: 280-285Crossref PubMed Scopus (79) Google Scholar reported increased irritability and anxiety during Ramadan. However, broad-based market research conducted throughout Turkey during Ramadan has shown that alcohol sales and consumption decrease noticeably during Ramadan. Consequently, decreased alcohol consumption results in a decreased ratio of fights, loss of self-control, and violence, all of which result in a decreased ratio of violence-induced penetrating injuries. In conclusion, our findings indicate that physiologic and behavioral changes during Ramadan may alter patient profiles in a surgical emergency unit.