A 35 year old presents with a two month history of epigastric fullness and discomfort. The barium swallow shown was obtained. The most likely diagnosis is 

A. Barrett's ulcer. 
B. esophageal carcinoma. 
C. foreign body. 
D. leiomyoma. 
E. ulcerative esophagitis. 

Answer D

Barrett's ulcer complicates Barrett's esophagus in 10-15% of patients. Radiologically, the ulcer is well circumscribed and can be deeply penetrating. Patients with these ulcers may present with pain, bleeding, obstruction, penetration into adjacent mediastinal organs or perforation. Advanced carcinoma of the esophagus may appear radiologically as a fungating mass or ulcerative lesion. Characteristically, the mucosa is irregular and the junction between tumor and normal mucosa is abrupt and clear. The stricture associated with carcinoma tends to be tapered rather than having rounded shoulders as shown in the x-ray. Furthermore, the axis of the esophagus is often deviated. 

A foreign body is an intrinsic problem and is unlikely to have a two month history.

A leiomyoma produces a segmental intraluminal filling defect which encroaches upon the lumen of the contrast-filled esophagus. This distinctive defect of the barium column has been described as "half-moon," "lacunar," and "crescent-shaped." As seen in the illustration, the overlying mucosa is smooth. Other distinctive features include obliteration or smoothing out of the mucosal folds over the tumor (the "smear effect"), delineation of a shelf at the upper and lower margins of the tumor (also seen), and splitting of the barium bolus on either side of the tumor ("forked stream"). 

Ulcerative esophagitis consists of linear ulcerations, with islands of preserved, thickened mucosa. It may lead to a peptic stricture. The transition from normal to abnormal esophagus is difficult to determine since the esophagus tends to be diffusely involved.