Interview: Dr Radislav Nakov - European Medical Journal
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Interview: Dr Radislav Nakov

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Dr Radislav Nakov President of the Association of Young Hepatogastroenterologists in Bulgaria; President of Bulgarian Society of Neurogastroenterology and Motility; Queen Yoanna University Hospital, Medical University of Sofia, Sofia, Bulgaria

What motivated you to specialise in gastroenterology over other disciplines?

As a medical student, I was fascinated by gastroenterology because it combines the intelligence of internal medicine and the boldness of surgery. In other words, you can use your brain and hands every single day. Therefore, the every day of the gastroenterologist is never boring.

Moreover, gastroenterology is an ever-improving field. We have witnessed cornerstone moments in the field: the discovery of Helicobacter pylori, biological therapy, and hepatitis C treatment. Nowadays, gut microbiota and artificial intelligence in endoscopy are receiving a lot of attention.

What are you currently researching and what areas of gastroenterology do you believe merit wider attention by the gastroenterology community?

I have started my scientific career with a PhD thesis in inflammatory bowel disease, in which I have assessed noninvasive markers such as fecal calprotectin and trefoil factor 3 for follow-up of patients with ulcerative colitis and Crohn’s disease.

Subsequently, I have been fascinated by the beauty of gut microbiota. Here I would like to thank Dr Gianluca Ianiro from Gemelli University Policlinic in Rome, Italy, who inspired and motivated me. I am proud that we have succeeded in creating the first stool bank in an Eastern European country (Bulgaria) and that we have reported the first series of successful and safe fecal microbiota transplantations (FMT) in Bulgaria.

In the last 2 years, our team have performed a few internet-based epidemiological studies on the prevalence of irritable bowel syndrome and functional dyspepsia. These were the first studies describing the prevalence of these gut-brain interaction disorders in Bulgaria. Moreover, in another study, we found that gastrointestinal (GI) symptoms were significantly more prevalent in the Bulgarian population during the coronavirus disease (COVID-19) lockdown than under normal circumstances.

The topic that I am most inspired by and that merits wider attention by the gastroenterology community are rare diseases in gastroenterology. For the last few years, I have been a member of the Bulgarian Centre of Excellence (CoE) for transthyretin amyloidosis, a rare disease presenting symptoms ranging from the peripheral nerves, heart, and GI tract. We have shown that GI manifestations are common in hereditary amyloidogenic transthyretin (ATTRv) amyloidosis and are present even before the onset of the polyneuropathy in some cases. Unfortunately, delays in diagnosis of ATTRv amyloidosis with GI manifestations commonly occurs because of the fragmented knowledge among gastroenterologists and general practitioners. Therefore, recently we have organised a working group of European gastroenterologists and neurologists that have now prepared recommendations for the diagnosis and management of transthyretin amyloidosis with GI manifestations.

Furthermore, I would like to congratulate the European Association for Gastroenterology, Endoscopy, and Nutrition (EAGEN) for organising a postgraduate course on rare diseases in gastroenterology.

How did you become involved with the Young Hepatogastroenterologists in Bulgaria and what is your role as President?

No association has potential without the active involvement of the younger professionals that will shape the future of the association. Unfortunately, a few years ago, a young gastroenterologist could not present a study at the National Congress of Gastroenterology in Bulgaria (BSGE); they were not involved in any activities of the National Society. Therefore, a group of young residents in Bulgaria were motivated to organise a conference for young gastroenterologists in Bulgaria. It was a great success and attracted more than 150 young doctors. The next year, we created theAssociation of Young Hepatogastroenterologists in Bulgaria. However, we were not recognised as an official gastroenterology section by the National Society. Here came the support of the United European Gastroenterology (UEG) Board and UEG Young Talent Group, who helped us to be recognised by the mother society by starting the dialogue between us.

Nowadays, the young gastroenterology section of Bulgaria is now one of Europe’s most active ones, actively organising a congress for young gastroenterologists with lecturesand hands-on training in Bulgaria, helping to organise the European conference for young gastroenterologists, and actively increasing its participation in the UEG’s (educational/support) programmes.

Similarly, what were the goals you set out to achieve when you became the President of the Bulgarian Society of Neurogastroenterology and Motility (BgSNM) and what is the long-term goal of this society?

The BgSNM was founded at the BSGE in 2019. There was an immense need to form such a group that united the Bulgarian gastroenterologists interested in neurogastroenterology and motility. The forming members of BgSNM are mainly young consultants and residents in gastroenterology who organised the first national population-based study for functional GI disorders prevalence in Bulgaria.

Our mission is to reduce the burden of disorders of the gut-brain interaction in Bulgaria by raising awareness and motivating scientific innovation and advances in medical care in the field of neurogastroenterology.

Our goals are to organise an annual scientific meeting, various workshops, and educational events. We would like to become active members of the European Society of Neurogastroenterology and Motility (ESNM) and collaborate with colleagues from all around Europe. As a young society, we have a lot to learn, and we believe that our experienced colleagues from Europe will help us to achieve our goals and develop as an organisation.

What would be your advice to fellow young gastroenterologists starting their careers and, in your opinion, what qualities are needed to become successful?

Nowadays, more young physicians should be inspired to do research. I believe that by performing studies, we ask ourselves essential clinical questions, which eventually make us better doctors. Therefore, in my opinion, the best clinicians are also excellent researchers.

Furthermore, communication and collaboration are crucial. Medicine is teamwork, and we should participate in working groups in order to improve ourselves. I would like to advise young gastroenterologists to apply for international clinical and research fellowships, to visit international congresses every year like the UEG Week, and to network with as many peers and experts as possible. I would also like to recommend every young gastroenterolgist to dive into the UEG Talent Pool and to apply to and actively participate in UEG programmes and positions in UEG committees and task forces.

You participated in a live case-based discussion titled ‘Endoscopy in patients with foreign body’ at this year’s UEG Week. What were the main takeaway messages from this session?

‘Foreign bodies in endoscopy’ was a very vivid and interactive session! It was a pleasure to discuss this topic with such great experts as Dr Ulrike von Arnim, Prof Alexander Meining, and Prof Peter Siersema. The main takeaway messages were to always assess patients with foreign bodies for a concomitant psychotic disorder, to be aware that a patient with food impaction may have underlying eosinophilic oesophagitis, and to use a suitable extraction device according to the type and location of the ingested foreign object.

Moreover, it is essential to know that if we have an asymptomatic patient with ingestion of a blunt and small object (except for batteries and magnets), we should observe him only clinically, without needing endoscopic removal.

Faecal microbiota transplantation is gaining prominence in the treatment of gastrointestinal diseases. What are the current concepts and future challenges?

The truth is that FMT has only been proven to be a safe and effective treatment for Clostridioides difficile infection; however, increasing evidence supports the role of FMT in other gastrointestinal and extraintestinal diseases. FMT has many potential applications, including in irritable bowel syndrome, inflammatory bowel disease, liver disorders, critically-ill patients, metabolic disorders, and neurological disorders. The use of FMT in chronic disorders such as inflammatory bowel disease is a real challenge because repetitive infusions are needed, and we still do not know how many FMT we need, what the interval between them should be, and what results to expect.

The future of FMT applications should focus on the urgent need for standardisation of regulations and protocols for donor screening to ensure patient safety. Moreover, another fundamental challenge is identifying the disorders for which microbiota modification may have an apparent clinical effect.