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]
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[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 (%)
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Non-Ramadan days
n (%)
|
P-value[a]
OR (95% CI)
|
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All admissions
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350244 (10.2)
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3076252 (89.8)
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|
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Years (2010-2019)
HD
|
3807 (0.91)
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45239 (0.67)
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<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]
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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]
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[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
