James Revier's timing, some might say, couldn't be better. When he was diagnosed with lung cancer in 1983 and told he had six months to live, he ended up at Stanford Health Care, where physicians offered him the chance to try some new treatments just out of research.

The chemotherapy they tried worked. "It worked so well, they were surprised," Revier said. "They started in March or April and by August they could no longer see the tumor. "Revier received radiation treatments, too, and after five years of clean check-ups, his Stanford doctors told him there was no reason for him to come back.

In 1983, fewer than 20 percent of lung cancer patients survived for five years after the diagnosis. One of those lucky few, Revier picked up his life again, although he was no longer the two-pack-a-day smoker he had been. The one thing that was still with him, however, was indigestion. "I've always had indigestion," he said.

Millions of other Americans have it, too. It's a word that describes a handful of unpleasant feelings centered in the body's core—the bloating, burning and belching that can make meal times miserable. Sometimes it's called heartburn, a label that's erroneous, of course, because it's acids from the stomach that are the problem; the heart isn't involved at all. Some digestive problems are more common in older age, but there is no gender or age category for distress around eating.

Why it happens

The causes for gastric upset are many: irritable bowel syndrome, stomach infection, medications, eating too fast, eating high-fat foods, stress, alcohol and smoking. In many cases, it's what doctors call gastroesophageal reflux disease (GERD). Each part of the digestive system has its own particularities, of course; trouble starts when there's interaction that goes in the wrong direction. With heartburn, acid from the stomach, designed to break down food, moves into the esophagus, whose tissues are seriously altered by the corrosive effects of regular acid reflux.

Most of us will experience that sensation at least once in a lifetime. When it begins to happen on a regular basis, the problem is serious. Typical treatments include medications that counteract the acids and promote the healing of damaged esophageal tissue. And more than $1 billion in over the counter medications are sold each year for acid relief. But while antacids offer pain relief, they do not reverse the potential damage to the esophagus. Once someone has suffered from acid attacks for five years, physicians recommend an endoscopy to look for signs of change.

What worries them are the changes that can happen to the esophagus after long-term exposure to acid. The rate of esophageal cancer in the lower esophagus has more than doubled in the last 25 years, making it by far one of the fastest increasing cancers in the U.S. The National Cancer Institute estimates 16,640 new cases this year. When someone has GERD, the odds increase for the development of a condition called Barrett's esophagus, a signal of tissue changes that raise the risk that cancer will develop there. Early detection, as with all cancers, is tied to the most effective treatment.

People like Revier, for whom gastric discomfort was the norm, may go for years without knowing about the changes taking place inside their esophagus. He found out only because he swallowed a piece of meat that was too big and he ended up in the emergency room. The physician who examined him noticed immediately that something was wrong. Revier was later diagnosed with Barrett's that had produced pre-cancerous cells in his esophagus.

Revier's health history and current medical conditions raised very high the risks for invasive surgery. By the time he found Ann Chen, MD, at Stanford Hospital & Clinics, he had gone through a series of unsuccessful hot laser treatments and the pre-cancerous cells were progressing toward cancer. Chen, who leads the Hospital's Barrett's Esophagus Program, became Revier's physician. For decades, "the treatment for Barrett's involved removing a part of the esophagus and pulling up the stomach to attach it to the remaining esophagus," she said. "That can be a risky procedure and cause long-term nausea, vomiting and complications. Nor has it been shown to prevent further Barrett's in the remaining esophagus."

The biggest change since those days has come because of the endoscope—a slender, flexible wand that can be sent into the esophagus with light-projecting optics and surgical tool attachments. Stanford opened a new endoscopy center in 2009, where patients can be treated for a wide range of conditions, with the endoscope's minimally invasive approach taking the place of traditional and more invasive surgical procedures.

Pankaj Jay Pasricha, MD, has been working to improve endoscopic tools since he entered the field. "Endoscopes have long been neglected in terms of the biotech and device industry," he said, "but things are beginning to change." New tools, like a flexible suturing device, have made endoscopically-performed surgical procedures more durable.

The digestive system is far more complex than most would assume. In fact, the nearly 20 feet that run from end to end contain an independent brain—not a solid organ like the one in the skull, but a system of 100 million neurons, an integral part of the tissues. This enteric (which means relating to the intestines) brain controls all the contractions and biochemical processes that support how humans process food and the pain we might feel in our intestines. The nerves are wired differently in each person, Chen said, which may explain why some people with just a bit of acid reflux experience severe pain while others with large amounts of acid reflux don't know they have a problem until cancer is already developed. Pasricha leads research at the Enteric Neuromuscular Disorders and Pain Laboratory at Stanford, also home to the NIH-funded Digestive Disease Center.

It was Pasricha who developed the endoscopic technology to deliver the first round of successful treatment for Revier. Instead of removing the Barrett's tissue with a scalpel, Chen was able to spray the pre-cancerous cells with a very cold gas to freeze them in a technique called cryotherapy. She followed that a few weeks later with radiofrequency therapy, burning off any residual Barrett's tissue with quick, short pulses of heat directed with an endoscope. There was no blood loss, she said, and less post-procedure pain, too.

"It really improves the care we can offer patients," Pasricha said. "We are able to do many more things than just surgery."

Revier did not need to be fully anesthetized for the cryoblation, which he was very happy about. "They did it and it went well," he said. "Everything went fine," Revier said, "and things are looking very good." Chen said check-up endoscopies of Revier's esophagus showed healthy new tissue regrowth and no sign of the Barrett's.

Next steps

The next step will be to refine who is at risk and who to treat, Chen said. Stanford is involved in research to follow patients and develop new techniques to diagnose patients earlier and to build preventive care strategies. "We think tobacco and alcohol are factors, and genetics likely plays a significant role," she said. "There are people who have acid reflux for years but never develop Barrett's or pre-cancerous changes. Then there are those who have only mild acid reflux and develop esophageal cancer at a young age. We just have not yet found the answer to why. We just can't predict it yet."

Revier still needs to watch what he eats. "I'll probably always take my medications, just to make sure I don’t have anything going back up to irritate that area," he said. "I keep thinking about what would have happened if it hadn't been for that piece of meat getting stuck." Having a place like Stanford, he said, "is one very good thing about living where we do if something comes up."