People who go to the hospital with stomach discomfort are often faced with two examination options: barium meal or gastroscopy. The trade-off is simple and clear: barium meal without intubation is less painful, but not clear; gastroscopy is clear, but intubation is painful. Translated into medical terms: barium meal examination is less efficient in diagnosis, but non-invasive; gastroscopy is more sensitive and specific, but invasive examination, there is the problem of patient tolerance. Before discussing these two options, let’s briefly explain the principles of barium meal and gastroscopy. Barium meal is actually an X-ray examination. After the X-ray passes through the body, it presents a contrasted image because of the different densities of various parts of the body. But the stomach and the surrounding tissue density is about the same, direct fluoroscopy except to see a large gastric bubble at the bottom of the stomach, nothing can be seen. So we let the patient drink a barium solution that does not transmit X-rays, and the barium is not absorbed after drinking, and it is evenly applied inside the stomach to outline the shape of the stomach. The stomach is deflated in the fasting state, the stomach walls overlap together, and a certain amount of gas needs to be injected in order to see clearly. The principle of gastroscopy is much simpler, is a long tube with a digital camera at one end, inside the tube, in addition to the transmission of digital images of the wire, there are some able to control the digital camera end of the bend up and down, through the handle to control the direction of this end of the digital camera. By extending the digital camera end into the stomach, the whole stomach can be observed up, down, left, right and back. The gastroscope also has a gas injection and suction device that can fill up the stomach cavity and suck the mucus out of the stomach for better observation. Understanding the principle, there is no disagreement as to which of the two is more accurate. To use an analogy, a barium meal is equivalent to looking at a skin shadow, while a gastroscope is high-definition digital. The actual situation also basically supports this comparison. Barium meal examination does not show abnormalities, the patient does not feel comfortable to do another gastroscopy results found to have disease, or barium meal examination shows that there is disease in the stomach, and then do gastroscopy results no disease, these two situations can often be encountered. Earlier statistical results show that gastroscopy as the standard, the final gastroscopy confirmed that there is disease, barium meal can only find about 50%, while the final gastroscopy proved that there is no disease, there are still nearly 10% of the barium meal misdiagnosed as having disease. That is to say, a patient after the barium meal found no disease, does not prove no disease, but also have to do gastroscopy to further exclude; if there is disease, but also first do not rush, there may be no disease. If you then consider that only gastroscopy can obtain a biopsy for pathological diagnosis, patients diagnosed with disease by barium meal still need to do another gastroscopy. On the contrary, if a gastroscopy has been done, it is not necessary to do another barium meal. In this way, the barium meal should be completely eliminated by gastroscopy. But the actual situation is that the barium meal is not completely eliminated, there are a considerable number of patients preferred barium meal examination. Analysis of the reasons, the patient’s factor is naturally the fear of intubation, the doctor’s factor and their own education. First, the patient’s fear is mostly from patients who have never had a gastroscopy before. However, if gastroscopy is really as painful as they think it is, then patients should be more resistant if the test is repeated. In reality, this is not the case: in a Canadian survey of outpatients, the ratio of preferred barium meal to preferred gastroscopy was 2:1 before the barium meal or gastroscopy was done, but after the test was completed, the ratio of preferred barium meal to preferred gastroscopy became 1:2, and many patients who did not have a preference for the test changed to a preference for gastroscopy. Considering that the people who did this study were radiologists, the results should be more plausible. This suggests that gastroscopy is not as painful as one might think. This should be due to improvements in gastroscopy equipment and advances in endoscopist techniques. For example, in China, almost every Chinese gastroenterologist in tertiary hospitals has experience in operating at least thousands or even tens of thousands of gastroscopies, and the level of proficiency should be as good as that of any specialist in any country in the world. And then there is the physician factor. In general, non-gastroenterologists are more inclined to barium meal, and there were some old-timers in gastroenterology who were also relatively inclined to barium meal, but such old-timers are becoming fewer and fewer. In the textbooks and education these doctors received, the status of barium meal is at least equal to that of gastroscopy, and patients are then inclined to choose barium meal once they are scared. But those textbooks were based on technology of an era when gastroscopy equipment was simply incomparable to what it is today. It can be said that the difference between a spherical screen and a multi-touch screen, the coarse diameter of the endoscope tube, the hard texture, and the inflexible operation required great courage on the part of both the doctor and the patient to do a gastroscopy. It can also be seen from the literature that most of the comparative studies on the advantages and disadvantages of gastroscopy and barium meal in the diagnosis of gastric diseases were published in the 1980s, and the results were increasingly favorable to gastroscopy, and basically ceased to exist after the 1990s. Because the difference is so obvious, even if someone still tries to compare them, the papers are no longer published. What has made the advantage of gastroscopy more obvious would be the widespread acceptance of the concept of early gastric cancer and precancerous lesions. This is where Japanese medical doctors have contributed the most. The widespread availability and improved level of endoscopy has allowed many lesions to be detected when they are very small and not deeply invasive, and to be removed by a variety of minimally invasive treatments to avoid progression to intermediate and advanced stages. The prevalence of gastroscopy has led to a decrease in the incidence of progressive gastric cancer in Japan from a country with a high incidence of gastric cancer to a country with a low incidence of gastric cancer every year. Most of these lesions are very small, at most one or two centimeters in size, and many of them are in the same plane as the surrounding normal tissues, not high or low, and can only be judged by gastroscopy based on the color of the mucosa and the fine structures like the gastric hollows, which are difficult to be detected by barium meal. Moreover, it is important to note that the symptoms of early gastric cancer patients are basically special in any way. Do not expect any special symptoms and sensations to guide doctors to detect early gastric cancer; most of these valuable lesions are unintentionally found during routine gastroscopy. Some scholars even suggest that for people in areas with high incidence of gastric cancer, men reaching the age of 40 or even lower should have a gastroscopy screening, especially those with a family history of gastric cancer. Because there is a long developmental accumulation period for the occurrence of gastric cancer, it may take several years to develop from early gastric cancer to progressive stage and more than ten years from precancerous lesion to gastric cancer, so if there is no abnormal finding in one complete and careful gastroscopy, it is at least certain that no gastric cancer will occur within ten years. However, a barium meal with no abnormal findings is not guaranteed for the reasons stated earlier. Although barium meal and gastroscopy seem to be in the status of “better than nothing”, they will not be completely eliminated yet. Because there are some rare gastric cancer, such as the diffuse gastric cancer called leather stomach, cancer cells in the submucosa growth, resulting in the stomach from the soft flesh cavity into a stiff crumpled leather products, gastroscopy plus pathological biopsy sometimes difficult to confirm the diagnosis, barium meal can provide a good clue. In addition, for patients who cannot undergo gastroscopy or are too weak to tolerate even anesthesia, barium meal is an alternative measure.