Since April 2014, he has been part of the team of the Second Internal Clinic in the same hospital. He specialized in gastroenterology at the Gastroenterology Clinic from 2014 to 2018. He obtained his speci alty in November 2018.
His professional interests are focused in the following areas: diagnostic and therapeutic upper and lower endoscopy, Endoscopic retrograde cholangiopancreatography - ERCP, manipulations under ultrasound and X-ray control. He is a member of the Bulgarian Scientific Society of Gastroenterology.
Dr. Tishkov, there is hardly a person who has not suffered from heartburn. When do you define this problem as a disease and, accordingly, prescribe treatment?
- Heartburn, or so-called heartburn, manifests itself as a burning sensation behind the sternum. This is an extremely common symptom among our patients. The frequency of these complaints progresses with age - occurring in 12% of the population under 20 and between 20-40% of people over 40
A large number of our patients manage to stop heartburn only with a change in lifestyle - diet, earlier dinner, avoiding smoking.
When complaints persist, burning behind the sternum progresses to the point of pain, accompanied by nausea, vomiting, loss of appetite, difficulty swallowing and weight loss - these are alarming symptoms that require a visit to a gastroenterologist for diagnosis and treatment.
Why does heartburn occur? Are they a problem of people who already have he alth problems with the stomach, or are the foods and our way of eating "to blame" for everything?
- Heartburn is caused by reflux of stomach contents - stomach acid, pepsin, deconjugated bile acids and pancreatic enzymes into the esophagus.
Pathological processes that manifest themselves with burning behind the sternum are extremely diverse: gastro-esophageal reflux disease, axial-hiatal hernia, Barrett's esophagus, esophagitis, carcinoma of the esophagus, carcinoma of the gastroesophageal junction, stomach ulcer/ duodenum, etc.
Among those listed, the most common cause of heartburn is attributed to gastroesophageal reflux disease - GERD, for the appearance of which great importance is attached to lifestyle and diet.
Which foods should people with such problems avoid?
- Foods that can induce heartburn and heartburn are: those that are rich in fat, chocolate, coffee, tea, coca cola, carbonated drinks, citrus fruits, spices, spicy products, etc..
Foods that would lead to regression of complaints are those rich in protein, fiber - cereals, fruits - banana, melon, watermelon, vegetables - beans, cauliflower, ginger, rice, bulgur, etc.
Besides food, lifestyle changes are also very important. Avoiding late dinner, wearing tight clothes and smoking is recommended. It is desirable to raise the top of the patient's bed by 25 cm during sleep.
What are the long-term risks of taking heartburn medications?
- A Latin sentence goes like this: “Dosis sola facit venenum!” - The dose itself makes the poison! This is a fundamental principle in pharmacology. Its meaning is that there is no harmless medicine. Therefore, medicines should be used carefully and only after a doctor's recommendation.
The main medications that are used to treat heartburn are the so-called proton pump inhibitors - PPIs and H2-blockers. Among them, the most widely advocated are PPIs, due to their better efficacy and harmlessness.
With long-term use of PPIs, the following side effects may occur: development of Clostridium difficile infection (Clostridium difficile belongs to the group of anaerobic, spore-forming bacteria), pneumonia, hypogastrinemia, hypomagnesemia, acute renal failure, osteoporosis, which increases the risk of spontaneous fractures, spontaneous bacterial peritonitis in patients with cirrhosis, hypovitaminosis of B12, which, in turn, increases the risk of developing megaloblastic anemia and dementia, reduced iron resorption, which can lead to the development of microcytic anemia etc.
How exactly can such drugs provoke the development of anemia?
- Suppression of gastric acid secretion when taking PPIs, leads to reduced absorption of macro- and micronutrients with the food taken. Vitamin B12 is of great importance for the normal course of metabolism and the proliferation (division) of cells.
Deficiency of this vitamin can lead to megaloblastic/macrocytic anemia with central and peripheral nervous system symptoms.
Decreased iron resorption can lead to iron deficiency/microcytic anemia because iron is a major part of the hemoglobin structure.
If longer-term treatment is required, how can we avoid these risks while still treating the heartburn problem?
- In order to avoid the manifestation of adverse drug reactions when using PPIs, it is necessary to achieve a balance between the dose of the medication and the duration of administration.
As I have already mentioned, the combination of drug therapy and lifestyle changes is of great importance to suppress the symptoms.
If longer-term PPI use is necessary, the following indicators should be monitored: peripheral blood count, biochemistry, electrolytes, iron level, vitamin B12, calcium, magnesium, etc.
In the presence of more significant deviations from their reference values, it is necessary for the patient to visit his attending physician, who will reduce the PPI dose and prescribe another type of medication to restore the newly appeared deviations.
Our favorite Bulgarian remedy is "extinguishing" acids with soda. Why do you define it as dangerous?
- It's a myth that baking soda helps soothe heartburn. Initially, it leads to relief of symptoms, but then there is a stimulated hypersecretion of gastric juice. The soda reacts with the hydrochloric acid in the stomach, as a result of which gas is formed - carbon dioxide, on the surface of which there is hydrochloric acid. And it, falling into the esophagus, further damages its mucous membrane.
In patients with heartburn, should more specific tests be done - both for diagnosis and for the choice of treatment and its follow-up?
- In case of persistence and progression of complaints, the patient should visit a gastroenterologist, who will prescribe the appropriate diagnostic and therapeutic measures. In the past, to determine the pathological process that leads to heartburn, great importance was attached to X-rays with barium slurry and ph-metry - the gold standard.
With the development of medicine, the main method of diagnosis, in the presence of pyrosis, is conducting an upper endoscopy - esophagogastroscopy. In our department of Interventional Gastroenterology, under the leadership of Dr. Petko Karagyozov, I have the honor of working with the most modern equipment for the diagnosis and treatment of diseases affecting the upper gastrointestinal tract.
Among the diseases listed, you mentioned gastroesophageal reflux disease - GERD as the most common cause of heartburn. What methods of diagnosis and treatment do you apply in this case?
- For its diagnosis, an upper endoscopy is of great importance, during which "gaping" of the cardia, reflux of stomach contents into the esophagus is detected. Depending on the severity of GERD, various changes in the esophagus mucosa are observed - from hyperemia to severe erosions.
The mainstay of GERD treatment is lifestyle change combined with PPI intake.
In case of a severe form of reflux and persistence of complaints, despite the applied treatment, it is appropriate for the patient to consult a surgeon for surgical treatment.
