Dr. Nikolay Georgiev: Patients neglect inflammatory bowel diseases

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Dr. Nikolay Georgiev: Patients neglect inflammatory bowel diseases
Dr. Nikolay Georgiev: Patients neglect inflammatory bowel diseases

Graduated from Medical University - Varna in 2012. In 2017 acquired the speci alty "Gastroenterology". In 2018, he was enrolled as a full-time doctoral student at the Medical University - Varna. In 2015, Dr. Georgiev was appointed to the Gastroenterology Clinic of UMBAL "St. Marina" in the maritime capital, in the position of specialist doctor, in 2017 - as a teaching assistant at the Department of "Internal Diseases", Board of Gastroenterology, Hepatology and Nutrition, where he continues to work until now. From the same year, he worked as a gastroenterologist at the "St. Marina".

Currently, he is also part of the team of specialists at "Klinika Nova", "Plazmamed clinic" and "Marine Medicine Transmed" MC, where he performs examinations and consultations.

He has completed a number of postgraduate qualifications and courses in highly specialized activities.

Dr. Nikolay Georgiev and I talk about modern diagnostics and therapy of inflammatory bowel diseases.

Dr. Georgiev, why are chronic inflammatory bowel diseases defined as an exceptional social problem?

- In the last 50 years, the incidence of chronic inflammatory bowel diseases (IBD) in Bulgaria has increased fivefold. This represents an extreme social problem, as those affected are mostly young people of an active age.

Are these patients diagnosed in time?

- Many patients ignore the problem or are referred too late to competent help, which delays the diagnosis for years. CVDs are serious diseases that lead to disability over time if timely treatment is not started. They affect the digestive tract.

One of the most common inflammatory bowel diseases is Crohn's disease. How is it different from ulcerative colitis?

- It is important to know that Crohn's disease is different from ulcerative colitis, which is another type of IBD but is limited to the colon. The symptoms of these two diseases are similar, but the areas of the digestive tract they can affect are different.

Crohn's disease can affect any part of the digestive tract - starting from the mouth to the anus, and especially often the so-called ileum (part of the small intestine (located generally in the lower right area of the abdomen) and the beginning of the large intestine.

The inflammatory process in Crohn's disease affects both the superficial and deeper layers of the intestinal walls, most often the small intestine, in which ulcerative changes are formed. In particularly strong manifestations of the disease, it is possible to break the integrity of the intestinal wall and form a channel (fistula) between adjacent intestinal loops, between the small intestine and other adjacent organs (for example, the bladder) or the skin.

In comparison, the inflammation caused by ulcerative colitis is limited only to the innermost wall of the intestine. Finally, the inflammations caused by Crohn's disease can be spaced out, whereas in ulcerative colitis this is not the case.

How to recognize the symptoms of Crohn's disease?

- Although symptoms vary between patients, some are more common than others. These are: symptoms related to inflammation in the digestive tract - diarrhea, in some cases with the presence of blood and/or mucus in the feces, pain during defecation, abdominal pain, localized mostly in the area around the navel, a feeling of incomplete bowel movement after going to toilet.

If you feel that you are experiencing symptoms that match some or all of the above, don't waste your valuable time, rather consult a specialist. Practice shows that self-medication or waiting for the symptoms to "go away by themselves" is counterproductive and usually leads to worsening of a person's condition - can lead to complications and significantly less favorable consequences. Earlier diagnosis is a prerequisite for more effective treatment.

You should also know that Crohn's disease is a chronic disease, which means that in these patients, periods of exacerbation of symptoms can be followed by remission, in which it is possible that the symptoms of the disease.

Are the reasons for its development clear?

- The causes of Crohn's disease still remain largely unclear. It is believed that diet and stress in everyday life can exacerbate the disease, but they alone cannot provoke its appearance. Recent research suggests that hereditary factors, genetic predisposition and the environment also contribute to its development.

The gastrointestinal tract normally contains harmless bacteria, many of which aid in digestion. The immune system basically attacks and kills foreign "elements", such as bacteria, viruses, fungi or other organisms. Under normal circumstances, the harmless bacteria in the gut are protected from such an attack.

In people with inflammatory bowel disease, however, these bacteria are perceived by the body as harmful invaders and provoke an immune system response. Cells travel through the blood to the intestines and create inflammation - a normal response of the immune system. However, this inflammation does not subside, which in turn leads to chronic inflammation, thickening of the intestinal walls, and ultimately, the onset of the symptoms experienced by patients.

Global data show that heredity is also relevant - affected by Crohn's disease in 5% to 20% of cases has a first-line relative (parent, child, relative) also suffering from Crohn's disease. But these data are hardly confirmed by statistics in Bulgaria, where 0.75% of patients have a relative with Crohn's disease, and just over 2% have a relative with ulcerative colitis.

It is believed that the risk of developing the disease is significantly greater when both parents have CKD. The disease is most common among people of European descent, especially Jews of similar ancestry.

Environment is also believed to play a significant role in the onset of the disease, especially in developed countries, more in urban than rural areas and in countries with northern rather than southern climates


What are the different types of Crohn's disease? Which of them is the most common in Bulgaria?

- Although Crohn's disease can affect all segments of the gastrointestinal tract - from the mouth to the anus, it is usually located in the large and small intestine. Because symptoms and complications in patients with similar diseases can vary, depending on the localization of the disease, it is important to know the type of disease with which they are diagnosed and how it can affect them.

The most common form of Crohn's disease is ileocolitis. It affects the end of the small intestine (ileum) and large intestine (colon). Such localization is observed in about 50% of diagnosed patients. Symptoms may include diarrhea or lower right abdominal pain. This type of Crohn's disease is often accompanied by significant weight loss.

Second in frequency is ileitis. This type affects only the ileum. It is diagnosed in about 30% of cases. The symptoms are the same as in ileocolitis. In more severe cases, complications may include fistulas or inflammation in the right lower quadrant of the abdomen.

Next is colitis, which only affects the large intestine. It is diagnosed in approximately 20% of cases. Symptoms include diarrhea, rectal bleeding and concomitant diseases in the perianal area (fistulas, fissures). Skin lesions and joint pain are also more common in this type than in others.

There are, of course, other types, but they are less common.

Crohn's disease can also be categorized according to its behavior. There are three types of presentation: stricturing, penetrating and inflammatory. Stricturing disease causes a narrowing of the intestine, which, in turn, can lead to its obstruction or a change in the thickness of the stool. Penetrating disease creates abnormal passages (fistulas) between the intestine and other organs or between the intestine and the skin. Inflammatory disease (non-stricturing, non-penetrating) causes inflammation without creating strictures or fistulas.

How is Crohn's disease diagnosed?

- Symptoms of Crohn's disease are often similar to other similar conditions, including bacterial infections

In order to confirm Crohn's disease, other potential causes of symptoms must first be ruled out.

The medical specialist questions the patient in detail about his complaints and makes a complete examination, looking for symptoms of the disease. If necessary, he can also perform certain examinations and manipulations. For example, a blood test that may show an elevated white blood cell count and other signs of inflammation and/or anemia (reduced red blood cell count, elevated C-reactive protein).

These are possible signs of the disease. Imaging tests, such as a barium smear x-ray of the gastrointestinal tract, allow more detail to be seen by increasing the contrast of the x-ray. Another imaging modality that can be used and allows viewing of fine details of the bowel wall, judging the extent of involvement and depth of infiltration, is abdominal computed tomography and CT-assisted enterography.

Stool examination with a test for occult bleeding, which is usually positive, or checking for a specific marker of intestinal inflammation - called fecal calprotectin - is also important. An endoscopic examination can also be included - in order to visually examine the inside of the alimentary canal.

What methods does the modern treatment of ulcerative colitis include?

- The main goal in the treatment of ulcerative colitis is to help patients regulate their immune systems better. Since there is still no cure for ulcerative colitis and there is a risk of exacerbations, a combined effect can be used to control the disease and restore the quality of life of these patients. Treatment includes a combination of medication, proper nutrition and diet, and sometimes surgical interventions.

The drugs used help suppress inflammation and repair the affected tissues. Symptoms, such as diarrhea, bleeding, and abdominal pain, are also reduced and effectively controlled with certain medications. With proper treatment, periods of remission are prolonged, which improves the quality of life of patients to a significant extent.


What is the place of biological drugs in the treatment of this disease?

- Biologic medications, also known as anti-TNF agents, are the most advanced treatment used for people with moderate to severe ulcerative colitis. Tumor necrosis factor (TNF) is a chemical produced by our bodies that causes inflammation. Antibodies are proteins that bind to these chemicals and allow the body to destroy the chemical and reduce inflammation.

Tumor necrosis factor-alpha (TNF-alpha) is a key pro-inflammatory cytokine and mediator of intestinal inflammation that is significantly expressed in patients with CKD. Tumor necrosis factor-alpha (anti-TNF-alpha) antagonists are the most effective anti-cytokine treatment in patients with Crohn's disease. They are usually included when patients do not tolerate or respond to conventional treatment. Before starting treatment with anti-TNF drugs, acute and chronic infections, such as tuberculosis, hepatitis B and hepatitis C, should be ruled out. There are different representatives of anti-TNF drugs: Infliximab, Adalimumab, Cetrolizumab, etc.

Another type of biological medication is anti-integrins. A typical representative of this group is Vedolizumab, which is an integrin antagonist approved for the treatment of Crohn's disease and ulcerative colitis. It is an intestinal tissue-specific IgG1 monoclonal antibody that binds exclusively to integrin alpha4beta7, which is the leading mediator of gastrointestinal mucosal inflammation.

There are other medicines as well. Different immune cells and inflammatory mediators are potential targets for new therapeutic strategies in Crohn's disease. Neutralizing antibodies and soluble receptor-based fusion proteins have been developed to bind to specific cytokines or cytokine receptors.

Most of them are currently in the phase of clinical trials: anti-CD3 antibodies (visilizumab), anti-interferon gamma antibodies (fontolizumab), antibodies against IL-2 (daclizumab), against IL-12/IL-23 (ustekinumab, briakinumab) and against IL-6 (tocilizumab).

When is surgical treatment necessary?

- In a quarter to a third of patients with ulcerative colitis, drug therapy is not completely successful and may require surgical treatment. The part affected by the disease is removed. And unlike similar cases of people with Crohn's disease, the patient is considered "cured." Nowadays, many modern operative methods are used, which then allow patients to maintain a full and good quality of life.

What diet is recommended?

“Many people think that their “diet” can be the cause of inflammatory bowel disease, but this is not the case. There is no magic diet that will solve all their problems – eliminate their symptoms and allow them to reduce or stop their medication. Such does not exist. Rarely, some people are lucky enough to identify the food that aggravates their condition and avoiding it really makes a difference. A well-balanced diet that includes foods from all the major food groups is the key for most people to achieve control of their condition. Good nutrition actually improves overall he alth and aids the healing process

For most patients with inflammatory bowel disease, a normal, balanced diet is more beneficial than a restricted diet. People who suffer from the disease and lose weight, especially adolescents whose growth is stunted, need a larger than average amount of food to meet daily needs. Limiting the intake of milk, fat, or foods high in residue may be helpful in certain circumstances, but only at the discretion of a physician

Most people with inflammatory bowel disease have no problem eating a normal, balanced diet, only having to limit certain specific foods that can cause problems in people with good gut he alth anyway.” explained the doctor

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