In Reply: We thank Dr. Keller for his kind remarks and feedback. However, we do not necessarily agree that the case presented was a bad example of a patient to be evaluated with a barium study. While a significant distal mucosal ring was identified on the study as the cause of the patient’s symptoms, this was not known before the examination. This patient could easily have had a subtle peptic stricture as the cause of the dysphagia. It is well known that subtle strictures can be missed with endoscopy. Further, if we knew that the patient had a significant distal mucosal ring before any testing, one could argue that all that was necessary was a dilation. When one knows, after the fact, what the cause of a patient’s symptoms are, one can always retrospectively determine which tests were necessary and which tests were not.
In our experience, we find that a well-performed barium study can identify many abnormalities that further direct a patient’s care. This examination, when performed correctly, provides both functional and anatomic information about the esophagus. We believe that too many patients undergo unnecessary endoscopic procedures and that endoscopy is not necessarily the initial examination in patients with dysphagia. As a result, the barium examination of the esophagus is underused. Furthermore, we view the barium examination and endoscopy as complementary examinations. We realize this is in many respects a philosophy. But Dr. Keller is also expressing a philosophy when he states, “I believe that patients with dysphagia and GERD are best served by initial endoscopy.” We, including most of our gastroenterologists and esophageal surgeons, believe that the barium examination is an important and often the best initial examination in patients with dysphagia.