Ulcerative peptic esophagitis may lead to the progressive replacement of squamous by columnar epithelium in the distal esophagus. A typical peptic ulcer (Barrett's ulcer) may develop in the columnar-lined segment, although this is a rare occurrence. Between 1975 and 1985 at Toronto General Hospital we treated 11 patients with penetrating peptic ulcer and acquired, columnar-lined esophagus. Presenting symptoms related to the ulcer were precordial and lower dorsal back pain in 4 patients, dysphagia in 6, and massive hemorrhage of the upper gastrointestinal tract in 4. None of the ulcers healed following a trial of medical therapy, and ultimately all 11 patients underwent antireflux procedures (gastroplasty and partial fundoplication). There was one operative death. Complete healing of the ulcer was observed in the 8 patients who underwent follow-up endoscopy between two and five months after operation. There has been no recurrence of symptoms resulting from ulcer in subsequent follow-up, which extends from 1 to 11 years (mean, 5 years). Adenocarcinoma developed in the columnar-lined segment in 2 of the 11 patients, which was diagnosed at 32 and 91 months following operation, respectively.