OBJECTIVE The purpose of this study was to assess the findings of acute radiation esophagitis in patients who undergo double- and single-contrast esophagograms and, specifically, to evaluate the presence or absence of a granular mucosa in these patients. METHODS We retrospectively reviewed the radiographic findings in 13 patients with acute radiation esophagitis who underwent double-contrast (n = 8) or single-contrast (n = 5) esophagograms at our hospital between 1988 and 1996. The barium studies were obtained 13-87 days (average, 39 days) after the initiation of radiation therapy because of acute odynophagia, dysphagia, or both. RESULTS Of the 13 patients with acute radiation esophagitis, the upper thoracic esophagus was involved in three patients, the mid esophagus in four, the distal esophagus in four, and the mid and distal esophagus in two. Of the eight patients who underwent double-contrast esophagograms, three (37%) had multiple small, discrete ulcers; four (50%) had a distinctive granular appearance of the mucosa; and one (13%) had both. In all eight patients, this ulceration or granularity was associated with variable esophageal narrowing within a known radiation portal. Of the five patients who underwent single-contrast esophagograms, two had esophageal narrowing, one had narrowing and ulceration, and two had thickened folds. Of the four patients who also underwent follow-up barium studies, three developed radiation strictures at the site of the previous injury. CONCLUSIONS In patients with acute radiation esophagitis, double-contrast esophagograms may reveal a variable segment of esophageal narrowing with multiple discrete ulcers or a distinctive granular appearance of the mucosa within a known radiation portal. In the appropriate clinical setting, the diagnosis should be suggested by this constellation of findings.