A barium swallow in a 65-year-old woman with dysphagia shows a mid-esophageal 'rat tail' or shouldering/apple core appearance with mucosal destruction and irregular luminal narrowing. Which is the most likely diagnosis?
- A Achalasia cardia — smooth tapered 'bird's beak' narrowing
- B Esophageal web — thin transverse defect in the upper esophagus
- C Carcinoma of the esophagus — irregular mucosal destruction, shouldering ✓
- D Diffuse esophageal spasm — corkscrew pattern
Explanation
Carcinoma of the esophagus on barium swallow shows characteristic mucosal destruction, irregular luminal narrowing with overhanging 'shouldering' or apple-core edges ('rat-tail' appearance), and proximal dilatation. These features indicate an infiltrating malignant lesion. Achalasia shows a smooth, symmetric, tapering narrowing ('bird's beak') at the gastro-esophageal junction with proximal dilatation. Esophageal webs are thin, eccentric shelf-like protrusions in the upper esophagus (Plummer-Vinson syndrome). Diffuse esophageal spasm shows a characteristic 'corkscrew' pattern from multiple simultaneous contractions.
Reference: Grainger & Allison's Diagnostic Radiology, 7th ed.
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Written and medically reviewed by the StethoPrep medical team.