Keywords
fasting - hemorrhoids - anal fissure - intermittent fasting
Introduction
Benign anorectal diseases encompass conditions affecting the rectum and anus, such
as hemorrhoids, anal fissures, abscesses, and fistulas. These conditions can significantly
diminish quality of life, causing discomfort, pain, and altered bowel habits. Among
these, hemorrhoidal disease (HD) and anal fissure (AF) are commonly encountered in
general surgical practice. The exact etiopathogenesis of HD and AF remains unclear;
however, excessive straining and chronic constipation are widely recognized as contributing
factors. Chronic constipation can lead to indigestion and bloating, which exacerbate
these conditions.[1]
[2]
[3]
[4]
Intermittent fasting (IF), characterized by alternating periods of eating and fasting,
has garnered attention for its potential health benefits, including weight loss and
improved metabolic profiles. Studies have suggested that IF may influence anorectal
diseases differently. For instance, some evidence indicates that fasting could mitigate
hemorrhoidal symptoms. Hemorrhoids, caused by increased venous pressure during straining,
may be less likely to flare up when fasting regulates bowel movements.[5]
[6]
[7]
[8]
[9] Notably, an animal study by Hong et al.[10] demonstrated that IF reduced hemorrhoid severity by attenuating inflammation in
the anal veins.
Conversely, IF may exacerbate conditions such as AF. Anal fissures, small yet painful
tears in the anal mucosa, are often linked to hard stools and straining. The dehydration
associated with fasting could result in harder stools, increasing the risk of fissure
development and worsening existing ones. Additionally, prolonged fasting and delayed
meal timing may limit fluid and fiber intake, further predisposing individuals to
fissures.
Another concern lies in the potential reduction of lubrication in the anal canal during
fasting periods, which could contribute to microtrauma and increase the risk of anal
fistulas. These abnormal connections between the anal canal and skin can become infected,
necessitating surgical intervention.[11] The dual effects of fasting—alleviating hemorrhoid symptoms while potentially exacerbating
fissures and other conditions—highlight the complex relationship between IF and benign
anorectal diseases.
Ramadan fasting, a religious practice observed by Muslims worldwide, entails refraining
from eating, drinking, and smoking from sunrise (Sahur) to sunset (Iftar) for 28 to
30 days. The lunar-based Islamic calendar results in Ramadan shifting annually by
approximately 11 days, influencing fasting durations that range from 12 to 22 hours
depending on the season and geographical latitude.[12]
[13] During this period, gastrointestinal disturbances may arise from prolonged fasting
and reduced fluid intake, particularly in hot climates or during longer daylight hours.
These challenges may disproportionately impact those with pre-existing anorectal conditions.
Despite the growing popularity of intermittent fasting for weight loss and overall
health benefits, literature on the association between long intermittent fasting and
benign anorectal diseases (such as HD or AF) is limited. Therefore, this essay aims
to investigate the potential effects of extended periods of intermittent fasting on
these medical conditions. By examining available research and clinical data, we can
gain a better understanding of the possible risks and drawbacks associated with prolonged
fasting for those with existing digestive issues.
Material and Methods
To better understand the relationship between IF and anorectal diseases, we conducted
a cohort study using retrospective analysis of data taken from the outpatients' records
of a single hospital. The study was performed by the ethical standards of the 1964
Declaration of Helsinki and its later amendments. Strengthening the Reporting of Observational
Studies in Epidemiology (STROBE) guidelines were used when reporting this observational
study.[14]
In this study conducted between January 1, 2010, and December 31, 2019, the researchers
aimed to compare the admission rates for hemorrhoids and fissures between two groups
of patients: those who were admitted during the fasting month of Ramadan, and those
who were admitted outside of Ramadan (the control group). Ramadan months were identified
using the Islamic lunar calendar and cross-verified with local religious authorities
for accuracy in matching admission records. The study excluded foreign patients, and
the patient data was collected using ICD-10 diagnosis codes.
The primary endpoint of the study was to determine whether there were any differences
in admission rates between the two groups. To minimize bias, patients with coexisting
anorectal conditions, chronic gastrointestinal diseases, or incomplete medical records
were excluded from the analysis. The researchers also considered changes in referral
and treatment policies, as well as admission criteria, over the course of the study.
As the fasting month of Ramadan involves abstaining from food and drink during daylight
hours, the researchers hypothesized that there may be a higher incidence of hemorrhoids
and fissures during this period. Previous studies have shown that dehydration and
changes in bowel habits can increase the risk of these conditions. To enhance reliability,
seasonal variations in anorectal disease presentation were accounted for by stratifying
the control group across equivalent months from the Gregorian calendar. Thus, the
results of the study could help to inform treatment and prevention strategies for
patients with HD and AF.
Ethical Approval
This study was approved by the Institutional Ethics Committee of the University of
Health Sciences, Istanbul Umraniye Training and Research Hospital (Approval Date:
2024, Decision No: 425/443). Written informed consent was waived due to the retrospective
nature of the study. All patient data were anonymized before analysis to maintain
confidentiality.
Statistical Analysis
All statistical analyses were performed using IBM SPSS Statistics for Windows, version
20.0 (IBM, Armonk, NY, USA). Variables are expressed as mean and standard deviations
(SD) or as medians (range) depending on their distribution. Categorical variables
were expressed as frequencies and percentages. The Chi-square with Yates' correction
method was used for comparison of continuous parametric variables. The Odds ratio
and 95% confidence interval were used to determine the strength of the association.
The statistical results were presented with a 95% confidence interval. To further
enhance robustness, sensitivity analyses were conducted by excluding extreme outliers
and re-running the statistical tests. The differences were considered statistically
significant if the p-value was less than 0.05.
Results
A total of 49,046 admissions for HD and 33,480 admissions for AF were reviewed in
this study. [Table 1] presents the distribution of admissions during the study period, revealing distinct
trends in admission patterns between the Ramadan and non-Ramadan periods. The study
compares HD and AF admissions during Ramadan to those during a day-adjusted one-month
period outside of Ramadan. [Figure 1] shows the yearly distribution of HD admissions over 10 years for the Ramadan and
non-Ramadan groups. [Figure 2] presents the yearly distribution of AF admissions over the same period. Although
yearly variations are evident, the 10-year evaluation provides a robust basis for
more accurate conclusions.
Table 1
Evaluation of changes in HD and AF
|
Ramadan days
n (%)
|
Non-Ramadan days
n (%)
|
P-value[a]
OR (95% CI)
|
|
All admissions
|
350244 (10.2)
|
3076252 (89.8)
|
|
|
Years (2010-2019)
HD
|
3807 (0.91)
|
45239 (0.67)
|
<0.001
0.74 (0.71-0.76)
|
|
Years (2010-2019)
AF
|
2184 (0.62)
|
31296 (1.02)
|
0.053
0.96 (0.91-1.00)
|
Abbreviations: AF, Anal fissure; CI, Confidence interval; HD, Hemorrhoidal disease;
OR, Odds ratio.
a Chi-square with Yates' correction.
Fig. 1 Distribution of Hemorrhoidal Disease Admissions Over 10 Years: Ramadan vs. Non-Ramadan
Groups.
Fig. 2 Distribution of Anorectal Fissure Admissions Over 10 Years: Ramadan vs. Non-Ramadan
Groups.
Over 10 years, the study analyzed a significant number of admissions for HD and AF.
The results demonstrated that admissions for HD were substantially higher during Ramadan
compared to the non-Ramadan period, with a p-value of less than 0.001. This result
indicates a strong association between Ramadan fasting and the increased prevalence
of healthcare visits for HD during this month. However, no significant differences
were observed in admissions for fissures between the two groups (p = 0.053). Despite
the absence of statistical significance, a slight upward trend in AF admissions during
Ramadan was noted, warranting further investigation.
Discussion
In this study, the authors conducted a comprehensive analysis of the variation of
benign anorectal diseases during a long period of intermittent fasting. Their findings
revealed an increase in admissions of HD patients, but no significant difference among
AF patients. This study provides important insights into the impact of intermittent
fasting on benign anorectal diseases, shedding light on potential risk factors for
certain patient groups. The authors' thorough approach underscores the importance
of continued research in this area to better understand the effects of fasting on
anorectal health.
Ramadan fasting affects people in various ways. Farooq et al.[15] reported a prospective study of the physiological and neurobehavioral effects of
Ramadan fasting and found that pre-teen and teenage boys showed significant changes
in sleep and diet, which had impacts on body composition. It has been reported that
Muslims feast on foods rich in carbohydrates and fat during Ramadan. An increase in
fat intake and modifications to the circadian rhythms during Ramadan may negatively
impact metabolic control and gastrointestinal motility, thus contributing to constipation
and weight gain.[16]
[17] However, some studies have reported no changes in food intake during Ramadan.[18]
[19] Fasting occurs only during the daylight hours and brings about a major shift in
the timing of meals, which contributes to physiological changes in the gastrointestinal
system by changing physical activity and sleep patterns.[20]
[21]
Leiper et al.[22] studied the health effects of Ramadan fasting and highlighted a reduction in drug
compliance, significant metabolic changes, and dehydration. During Ramadan fasting,
Muslims undoubtedly become dehydrated over time. However, the correlation between
daily water loss and outcomes is limited. Every year, millions of Muslims undergo
Ramadan fasting, and dehydration effects can be observed in some cases. However, no
adverse consequences on health have been directly attributed to the intermittent dehydration
that may occur during Ramadan.[22]
[23] If an individual eats and drinks enough before and after the fasting period, it
is possible that no metabolic or organic complications arise. However, the eating
time or non-fasting period can be seven hours or less, and the individual consumes
more during this time, which can limit fluid intake. Low fluid intake or dehydration
was neither evaluated nor proven in our study.
Various studies have reported different results regarding dietary fiber intake during
Ramadan. Khaled et al.[24] found a decrease in consumption, while Rakicioglu et al.[25] observed no change. It is recommended that patients with HD and AF follow a high-fiber
diet and consume enough fluids to prevent constipation. Therefore, restricting fiber
and fluid intake for a long period during Ramadan could worsen constipation.[1]
[26] Trepanowski et al.[27] and Gokakin et al.[28] conducted studies on the impact of fasting on human health and highlighted the mixed
findings related to health during Ramadan fasting. The authors identified potential
reasons for the inconsistent findings among studies, including differences in daily
fasting time, smoking habits, history of oral medications, and eating habits. In our
study, we could not assess smoking habits, oral medication history, and eating habits
due to the nature of the study. However, since these factors can affect the gastrointestinal
system and lead to constipation, further prospective studies are needed to investigate
this issue.
Symptomatic hemorrhoids are associated with advancing age, prolonged sitting, straining,
and chronic constipation. It is unclear if this relationship is causal.[3] The most common causes of AF are local trauma after excessive straining during defecation,
such as passing hard stool or prolonged diarrhea.[15]
[26] Fasting, especially with low fluid intake for an extended period, can cause gastrointestinal
disorders and constipation. Chronic constipation was found after fasting for one month,
which increased straining during defecation.[1]
[2]
[26] Shatila et al.[29] surveyed Ramadan and found constipation in 61% of participants and dehydration in
48%. In our study, we observed higher rates of HD admission during Ramadan, but the
admission rate for AF did not change. Although the etiology and pathogenesis of HD
and AF are different, chronic constipation may be associated with both conditions.
The different admission trends for HD and AF observed in our study may reflect the
unique pathophysiological responses of these conditions to fasting, highlighting the
need for further focused research. Instead, it is possible that other concurrent factors
during Ramadan, such as altered healthcare-seeking behavior, contributed to the observed
trends. Future research should also consider geographical differences in fasting durations,
which vary significantly and may influence outcomes differently.
Strengths and Limitations
Strengths and Limitations
The main strength of this study is its comprehensive analysis of a large patient cohort
from hospital records. However, several limitations must be considered. This study
is a case-control study, which inherently carries a risk of selection bias. Additionally,
it does not account for individual fasting patterns during Ramadan, which could influence
the incidence of HD. While hemorrhoids are commonly associated with constipation,
they may also be triggered by prolonged efforts during defecation. The data observed
may be influenced by the combined effects of fasting and predisposition to HD, which
are not fully captured in this study.
Another limitation is the unbalanced enrollment of participants from the emergency
department versus general surgery outpatient clinics. Increased admissions during
Ramadan may reflect multiple factors, including decreased admissions for other conditions.
Future prospective studies with a novel design and a control group are needed to provide
further validation of our findings.
Moreover, it is crucial to differentiate between various types of fasting when researching
the effects of fasting. Ramadan fasting, which allows for the consumption of fluids
and food during specific periods, may have different physiological impacts compared
to other types of intermittent fasting that involve total abstinence from food and
drink.[30] The side effects of fasting, such as hemorrhoids, may not fully manifest until after
the Ramadan fasting period concludes, highlighting the importance of distinguishing
between different fasting protocols. There may also be confounding variables that
were not accounted for, affecting the development of benign anorectal disease. Therefore,
the differentiation of various types of fasting is essential for accurate and valid
research conclusions.
The findings of the study raise concerns about the association between intermittent
fasting and an increased risk of HD. It underscores the need for further research
to explore the underlying mechanisms contributing to this increased risk. Understanding
these mechanisms is crucial to prevent potential health risks and adverse effects
associated with intermittent fasting diets. Individuals who choose to follow such
diets should consider these findings when making their dietary choices.
While this study is valuable, it is essential to differentiate between the various
types of intermittent fasting to validate conclusions. The study acknowledges the
differences between different types of fasting, including Ramadan fasting, which allows
for the consumption of fluids and food. This differentiation is necessary for accurately
interpreting the research findings. The research should consider the specific fasting
protocols to provide conclusive insights based on the type of fasting being examined.
In essence, the results of this study highlight genuine concerns about the effects
of prolonged intermittent fasting on anorectal diseases. There is a need for in-depth
research to identify preventive measures that can mitigate potential health risks
associated with long-term intermittent fasting. Further studies should adopt a comprehensive
approach, considering all types of intermittent fasting, to yield more precise conclusions
and well-formulated recommendations.
In conclusion, this study provides valuable insights into the impact of intermittent
fasting on anorectal diseases like hemorrhoids and fissures. It highlights the potential
risks associated with prolonged intermittent fasting, which should be considered when
considering such diets. The study also emphasizes the need to differentiate between
different types of fasting to validate its conclusions. Further research initiatives
are necessary to gain a deeper understanding of the condition and develop measures
to mitigate the health risks associated with intermittent fasting.
Bibliographical Record
İlyas Kudaş, Fatih Başak, Hüsna Tosun, Yahya Kemal Çalışkan, Fethi Sada Zekey, Aylin
Acar, Tolga Canbak. Exploring the Connection: How Does Fluid Restrictive Intermittent
Fasting Affect Benign Anorectal Diseases?. Journal of Coloproctology 2025; 45: s00451804912.
DOI: 10.1055/s-0045-1804912
