Diseases of the Esophagus (2021)34,1–9

DOI: 10.1093/dote/doaa080

Original Article

Accuracy of Achalasia Quality of Life and Eckardt scores for assessment of

clinical improvement post treatment for achalasia

Samuel Slone,1 Ambuj Kumar,3 John Jacobs,1,2 Vic Velanovich,2,4 Joel E. Richter1,2
1 2
Division of Digestive Diseases and Nutrition Joy McCann Culverhouse Center for Swallowing Disorders

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3 4
Research Methodology and Biostatistics Core Division of General Surgery, Morsani College of Medicine
University of South Florida, Tampa, Florida, USA

SUMMARY. Achalasia Quality of Life (ASQ) and Eckardt scores are two patient-reported instruments widely
used to assess symptom severity in achalasia patients. ASQ is validated and reliable. Although Eckardt is commonly
used, it has not been rigorously assessed for validity or reliability. This study aims to evaluate (i) the accuracy
of Eckardt and ASQ for assessing improvement post-treatment (predictive validity), (ii) accuracy of Eckardt and
ASQ for assessing improvement post-treatment with pneumatic dilatation (PD) versus surgical myotomy (predictive
validity), and (iii) convergent validity of Eckardt and ASQ tools. Patients with achalasia treated between 2011 and
2018 were eligible. Both instruments were administered by telephone. Treatment failure was determined by the
review of medical records by two clinicians. The predictive ability of ASQ and Eckardt instruments in identifying
treatment successes and failures was determined using receiver operating characteristics analysis and summarized
as area under the curve (AUC). A total of 106 patients met inclusion criteria with 39 PD, 51 Heller myotomy, and
16 per-oral endoscopic myotomy. A review of medical records and esophageal testing revealed 13 failures (12%).
AUC for Eckardt was 0.96 (95% confidence interval [CI] 0.87–0.99] and ASQ 0.97 (95% CI 0.92–0.99). The
Eckardt cutoff 4, and ASQ, cutoff 15, were 94% and 87% accurate in identifying treatment successes versus failures,
respectively. The correlation coefficient between the two tools was 0.85. In conclusions, (i) ASQ and Eckardt scores
are valid and reliable tools to assess symptom severity in achalasia patients, (ii) both instruments accurately classify
treatment successes versus failures, and (iii) the choice of tool should be informed by the physicians and patients’
values and preferences and repeat physiologic testing may be reserved for treatment failures with either instrument
and patients classified, as treatment successes may be spared routine physiologic testing in the long term.
KEY WORDS: achalasia, heller myotomy, pneumatic dilatation, achalasia questionnaires.

INTRODUCTION there appears to be little correlation between objec-

tive physiological measurements of achalasia and
Achalasia is a motility disorder of the esophagus patient-perceived symptoms.4 Therefore, outcomes
that commonly presents with symptoms such as of achalasia treatment have generally included both
dysphagia, regurgitation of undigested food, chest patient-reported symptomatic changes and changes in
pain, weight loss, recurrent aspiration, or nocturnal physiological testing. The assessment of improvement
cough.1 Myenteric neurons in the esophagus coor- and long-term prognosis after medical or surgical
dinate esophageal peristalsis and the relaxation of treatment is important. Simple questionnaires are
the lower esophageal sphincter (LES). In patients desirable, which would complement follow-up with
with achalasia, these neurons are either decreased or the TBS.5
absent, leading to reduced peristalsis and absence of The Eckardt score and the Achalasia-specific
relaxation of the LES. This results in impaired flow quality-of-life questionnaire (achalasia-DSQoL or
and stasis of undigested food and secretions in the ASQ) are two instruments used to assess the quality
esophagus leading to the above symptoms. The diag- of life (QoL) and symptom severity before and
nosis of achalasia is suggested by clinical history and after treatment for achalasia. The Eckardt score,
confirmed with high-resolution manometry (HRM)2 first described in 1992 and based on the clinical
and timed barium swallow (TBS).3 Interestingly, experiences of the authors, is a simple questionnaire

Address correspondence to: Joel E. Richter, MD, Professor and Director, Division of Digestive Diseases and Nutrition, Joy McCann
Culverhouse Center for Swallowing Disorders, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL 33612, USA. Email: Jrichte1@usf.edu

© The Author(s) 2020. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus.
All rights reserved. For permissions, please e-mail: journals.permissions@oup.com 1
2 Diseases of the Esophagus

widely used in evaluating the efficacy of achalasia All consecutive achalasia patients who underwent
treatment.6 Because the items chosen were based PD, Heller myotomy (HM), or per-oral endoscopic
on expert opinion, this can be considered a type of myotomy (POEM) for achalasia at the University of
‘face’ validity.7 The scoring system involves questions South Florida between 2011and 2018 were eligible
related to the frequency of common esophageal for inclusion in the study. Patient information was
symptoms usually associated with achalasia including retrieved from an HRM database. Information on
weight loss, dysphagia, regurgitation, and retrosternal demographics (age, gender, body mass index [BMI])
pressure. A score of 0–3 was applied if the symptoms and procedure were collected from electronic medical
never occurred, occasionally, daily, or with each records (EMR). All patients had achalasia diagnosed
meal.3 A score of 0–3 was also given to the degree via HRM according to the Chicago Classification2
of weight loss (Table 1A). A symptom score of 0–1 and TBS.3 Patients were excluded if they were <18
correlates to clinical stage 0, 2–3 to stage I, 4–6 to or >90 years of age, chose not to participate in the
stage II, and > 6 to stage III (3). Both stage 0 and I study, or could not be reached after three phone call

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indicate significant symptom relief.6 Treatment was attempts. A prepared, IRB approved script (Supple-
considered a failure at stages II and III.6 Although mentary Material 1) was used to orient the patients
widely used in all the large European clinical trials,8–10 about the research process over the phone. After the
the Eckardt score has not been validated rigorously administration of informed consent, both the ASQ
as a tool for evaluating symptomatic improvement in and Eckardt questionnaires were administered in suc-
achalasia patients. cession over the telephone.
Designed by Urbach and colleagues,11 the ASQ is To assess post-treatment success or failure, the
a validated 10 question questionnaire where patients reference standard was applied to all patients. The
can quantify and qualify symptoms of achalasia reference standard was a review of all follow-up office
such as dysphagia to both solids and liquids, specific notes by the senior gastroenterologist or surgeon
types of food, other associated symptoms, and assessing symptom improvement and available results
overall health in relation to achalasia (Table 1B). The from esophageal function testing including TBS,
questionnaire was constructed via expert opinion, HRM, endoscopy, and gastric emptying studies. A
interviews with seven achalasia patients, and data second gastroenterologist reviewed all cases indepen-
gathered from a long-form questionnaire prospec- dently. Any disagreement was resolved by consensus.
tively administered to 70 achalasia patients. The Investigators applying the reference standards were
scores were tallied with a larger score suggesting blinded to the results of the index test (i.e. Eckardt
more severe symptoms of achalasia on a scale of and ASQ scores). Since all patients did not have repeat
10–31, which can be normalized to a 0–100 scale esophageal function testing, the primary parameter
if desired. In a multicenter study of 50 achalasia of success was symptomatic improvement, followed
patients, they found similar ASQ improvement for by the results of esophageal function testing. That
both the surgical and pneumatic dilatation (PD) is, the patient-reported symptomatic improvement
groups at 1 and 5 years.12 was given priority over esophageal function testing.
Although both questionnaires are being used in Abnormal esophageal function testing was defined
clinical practice and clinical trials for assessing pre- by (i) TBS at 5 minutes with >5 cm height retention
treatment symptom severity and treatment responses or TBS not improving at least 50% in 5 min height
in patients with achalasia, a head-to-head perfor- retention from pre-treatment values,13,14 (ii) HRM
mance comparison of ASQ and Eckardt has not showing integrated relaxation pressure (IRP) >15,
been performed. The goals of our study were to (i) (iii) abnormal 4-hour gastric emptying study >10%,
compare the overall accuracy of Eckardt score with or (iv) important abnormalities noted on endoscopy
the ASQ for assessing improvement post-treatment (i.e. stricture, esophagitis, tight esophagogastric
(predictive validity), (ii) evaluate score change after (EG) junction, or retained food). We did not con-
PD versus surgical myotomy (predictive validity) sider gastroesophageal reflux disease (GERD) with
simultaneously for both tests, and (iii) asses the esophagitis or esophageal stricture abnormal tests,
correlation between Eckardt score and ASQ to as these are considered potential complications of a
determine post-treatment improvement (convergent successful myotomy.
validity).

STATISTICAL ANALYSIS
METHODS
Categorical demographic variables were summarized
We performed a cross-sectional analytic study between as rates/percent and continuous as mean/median and
October 16, 2018 and January 17, 2019. The study was standard deviations/interquartile range (IQR). If both
approved by the institutional review board (IRB) at instruments measure patient-perceived symptoms of
the University of South Florida (Pro00034825). achalasia, there should be a correlation. This can be
 Accuracy of Achalasia Quality of Life and Eckardt scores 3

TABLE 1 Eckardt questionnaire and ASQ questionnaire

Eckardt Questionnaire
Dysphagia Regurgitation Retrosternal pain Weight loss (kg)

0 None None None None

1 Occasional Occasional Occasional <5
2 Daily Daily Daily 5–10
3 Each meal Each meal Each meal >10

ASQ questionnaire
1. How much has achalasia limited the types of food you have been able to eat in the last month?

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a. Not limited at all (I can eat and drink all the foods that I would like to.)1

b. Somewhat limited (I can eat and drink most of the foods that I would like to.)2

c. Moderately/Severely limited (I can eat and drink very few of the foods I would like to.)3

The following is a list of food types that may or may not cause you difficulty in swallowing. Please indicate which of the following types of
foods you are able to swallow without experiencing any problems such as pain or food ‘sticking’ as it goes down. If you are not sure
whether you can swallow a type of food without problems, please make you best guess.

2. Raw hard fruits and vegetables

a. Can swallow without problem.1

b. Can swallow, but with some difficulty.2

c. Can swallow with great difficulty or not at all.3

3. Rice

a. Can swallow without problem.1

b. Can swallow, but with some difficulty.2

c. Can swallow with great difficulty or not at all.3

4. Clear fluids (water, juice, coffee, tea)

a. Can swallow without problem.1

b. Can swallow, but with some difficulty.2

c. Can swallow with great difficulty or not at all.3

5. How often in the past month have you need to drink water while eating to deal with food caught in your esophagus?

a. Never/Rarely1

b. Sometimes2

c. Frequently/every time I eat3

6. How often have you experienced pain when eating during the past month?

a. Never1

b. Rarely2

c. Sometimes3

d. Frequently/every time I eat4

Continued
4 Diseases of the Esophagus

TABLE 1 Continued

7. During the past month, how much of a problem was heartburn (a burning pain behind the lower part of the chest) for you?

a. No problem1

b. Mild problem2

c. Moderate problem3

d. Severe problem4

e. Very severe problem5

8. When you sit down to eat a meal, are you bothered by how long it takes you to finish eating?

a. No, I eat as quickly as I like1

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b. Yes, I am bothered by how long it takes me to eat2

9. Has having achalasia limited your lifestyle?

a. No, it is not at all limiting (My daily activities have not changed.)1

b. Yes, it has limited my lifestyle (it has affected some areas, and I can no longer participate in all activities I want to do.)2

10. How much do you agree with the following statement about how satisfied you are with your health in regard to achalasia?

I am satisfied with my health in regard to achalasia.

a. Strongly agree1

b. Agree2

c. Neither agree or disagree3

d. Disagree4

e. Strongly disagree5

considered convergent validity. The diagnostic accu- RESULTS

racy of QoL outcome assessment using ASQ versus
the Eckardt score was assessed using the receiver In total, 224 patients met the inclusion criteria,
operating curve (ROC) analysis and summarized and 106 patients (54 men and 52 women) com-
as the area under the curve (AUC) along with 95% pleted the telephone interview. The reasons for non-
CI. The ability of each instrument to accurately participation were primarily not being able to reach a
identify patients with a successful treatment outcome patient by telephone in three attempts (n = 116), and
on a failed treatment outcome is an assessment of one patient did not agree to participate in the study.
predictive validity. The same analytic method was The mean age with standard deviation in years of the
used to assess the performance of individual items patient population was 62 ± 16 (median 65 months;
on both questionnaires. The ROC analysis was also IQR 23). The mean BMI with the standard deviation
used to determine the overall optimal cutoff for was 26.8 ± 6.9. Overall, the primary treatment for
both questionnaires and each item of the QOL these 106 patients were PD (n = 39; 37%), HM
tools by assessing the thresholds associated with (n = 51; 48%), and POEM (n = 16; 15%). The Chicago
maximum sensitivity and specificity. The correlation Classification of achalasia type and percent treated
between responses on two questionnaires was assessed with surgery were as follows: type I, 15 (67% surgery);
using non-parametric Spearman’s rank correlation type II, 70 (67% surgery); type III, 13 (46% surgery);
test and reported as the correlation coefficient. and unknown type, 8 (37.5% surgery). The average
Statistical significance for all comparisons is set at a length of follow-up from the most recent procedure
P value <0.05. All analyses were performed using the (39 PD, 51 HM, and 16 POEM) was 42.4 ± 17 months
IBM SPSS statistical analysis software (IBM Corp. (median 44 months; IQR 29).
Released 2017. IBM SPSS Statistics for Windows, The post-procedure symptomatic assessment
Version 25.0. Armonk, NY: IBM Corp.). information was available for all 106 patients. In
 Accuracy of Achalasia Quality of Life and Eckardt scores 5

addition, 48% (n = 51) patients underwent repeat

esophageal function testing post-procedure. Overall
88% (n = 93) of patients were treatment successes (PD
37, HM 42, POEM 14). Fifty-two percent (n = 48) of
the successes were based on symptom improvement
only, and 48% (n = 45) showed improvement on TBS
(N = 43) or HRM (N = 2) post treatment as well.
Overall, 13 patients (12%) were considered treat-
ment failures based on a review of the EMR and
repeat esophageal function testing (PD 2, HM 9,
POEM 2). Details on failure patients are shown in
Table 2. Based on Chicago Classification, the fail-
ure rate was similar across all four groups ranging

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between 11 and 15%.

Predictive validation and discriminatory value of the

Eckardt scale and ASQ
There was a statistically significant difference in ASQ
Fig. 1 Receiver operating characteristic curves with area under
and Eckardt scores for treatment success versus fail- curve values for the Eckardt questionnaire and ASQ. (ASQ, Acha-
ure patients. The overall median ASQ score for treat- lasia Quality of Life; AUC, area under the curve; CI, confidence
ment success was 11 (IQR 3) versus 20 (IQR 6) for the interval; ROC, receiver operating curve).
treatment failures (P < 0.0001). Similarly, the median
Eckardt score for treatment success was 1 (IQR 2) ver-
sus 6 (IQR 3) for the treatment failures (P < 0.0001).
Patients treated with surgical interventions
Discriminatory value of the Eckardt score and ASQ As shown in Figure 2C, for patients treated with surgi-
As shown in Figure 1, the AUC for Eckardt ques- cal interventions, the overall accuracy of the Eckardt
tionnaire was 0.96 (95% CI 0.87–0.99) and for ASQ tool with a cutoff ≥4 was 91% versus 85% for ASQ
0.97 (95% CI 0.92–0.99). This is strong evidence for with a ≥15 cutoff. An Eckardt cutoff ≥4 correctly
the predictive validity of the instruments. For the identified 93% of treatment successes and 82% of
Eckardt score, the cutoff score of ≥4 had the best treatment failures. The ASQ cutoff ≥15, correctly
discrimination between improvement and failure after identified 82% of treatment successes and 100% of
treatment with a sensitivity and specificity of 85 and treatment failures in patients treated with surgical
96%, respectively. Similarly, for the ASQ, the cutoff interventions.
score of ≥15 had the best discrimination between
improvement and failure after treatment with a sensi-
tivity and specificity of 100 and 85%, respectively. The Convergent validation of Eckardt and ASQ tools
sensitivity, specificity, and accuracy associated with a The overall correlation between the Eckardt and ASQ
cutoff ≥2–5 for the Eckardt and ≥ 13–17 for the ASQ QoL questionnaires was strong, with a correlation
questionnaire are shown in Table 3. coefficient of 0.84 (95% CI 0.76–0.89). For patients
treated with PD, the overall correlation between the
Predictive value in assessing success of treatment after Eckardt and ASQ QoL questionnaires was strong
PD and HRM with a correlation coefficient of 0.79 (95% CI 0.60–
0.89). For patients treated with surgical interventions,
As shown in Figure 2A, the overall accuracy of the
the overall correlation between the Eckardt and ASQ
Eckardt tool with a cutoff of ≥4 was 94%. The overall
QoL questionnaires was strong with a correlation
accuracy of the ASQ with a cutoff ≥15 was 87%.
coefficient of 0.85 (95% CI 0.75–0.91).

Patients treated with PD

As shown in Figure 2B, the overall accuracy of the Discordance between tests
Eckardt tool for patients treated with PD with a cutoff There were 13 discordant test results (12%) of which
≥4 was 100% versus 95% for ASQ with a ≥ 15 cutoff. 11 were for treatment successes and 2 for treatment
An Eckardt cutoff ≥4 correctly identified 100% of failures. In all cases, the ASQ score (range: 15–18)
treatment successes and failures. The ASQ cutoff ≥15, was the primary reason for the discordance with the
correctly identified 89% of treatment successes and Eckardt score being normal and evenly distributed
100% of treatment failures in patients treated with PD. between 2 and 3.
TABLE 2 Details for the 13 achalasia patients considered treatment failures by the senior authors
6 Diseases of the Esophagus

Age (in Gender Chicago Procedure Current symptoms ASQ score Eckardt Evaluation post-initial treatment
years) classification score

68 Female I Pneumatic dilatation Dysphagia, heartburn, weight 28 6 Abnormal timed barium swallow after second procedure;
loss, chest pain myotomy planned
59 Male II Pneumatic dilatation Dysphagia, heartburn 20 6 Abnormal timed barium swallow after initial procedure; no
subsequent follow-up
43 Female I Heller myotomy Dysphagia, regurgitation 18 4 Abnormal timed barium swallow 3 years after initial procedure
65 Male II Heller myotomy Dysphagia 15 4 No follow-up after surgery as moved out of state
80 Female II Heller myotomy Dysphagia, heartburn, weight 15 4 Abnormal timed barium swallow after initial procedure
loss
76 Female II Heller myotomy Dysphagia, weight loss 20 5 Abnormal timed barium swallow, EGD showed stricture at
LES; no response to pneumatic dilatation for incomplete
myotomy
84 Male III Heller myotomy Dysphagia, regurgitation 21 6 Abnormal timed barium swallow after initial procedure;
Incomplete myotomy requiring repeat Heller myotomy after
survey
20 Male II Heller myotomy Dysphagia, regurgitation 19 4 Post-op gastroparesis diagnosed by gastric emptying test
38 Female II Heller myotomy Dysphagia, regurgitation 16 6 No follow-up after initial surgery
63 Female II Heller myotomy Dysphagia, regurgitation, weight 20 7 Paraesophageal hernia causing secondary obstruction
loss
62 Female Unknown Heller myotomy Dysphagia 21 3 EGD with retained food and esophagitis; pneumatic dilatation
performed without relief; subsequent timed barium swallow
abnormal
41 Female II Per-oral endoscopic Dysphagia, regurgitation, weight 27 9 Repeat EGD showed LES stenosis. Did not respond to simple
myotomy loss, heartburn dilatation. Abnormal timed barium swallow, incomplete
myotomy requiring repeat myotomy after initial survey
83 Male III Per-oral Endoscopic Dysphagia, Regurgitation 15 2 Abnormal timed barium swallow after initial procedure
myotomy

ASQ, Achalasia Quality of Life; EGD, upper endoscopy.

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 Accuracy of Achalasia Quality of Life and Eckardt scores 7

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Fig. 2 Proportions of patients correctly identified as treatment success or failures and accuracy with either Eckardt score and ASQ
questionnaire: (A) all treatment types, (B) pneumatic dilatation, and (C) surgery. (ASQ, Achalasia Quality of Life).

TABLE 3 Sensitivity, specificity, accuracy, number needed to diagnose, and misdiagnose associated with a cutoff ≥2–5 for the eckardt and
≥13–17 for the asq questionnaire

ASQ ques- Cut off Value Treatment success Treatment failures Accuracy Number Number Likelihood to be
tionnaire correctly identified correctly identified (%) needed to needed to diagnosed or
(%) (%) diagnose misdiagnose misdiagnosed

≥13 67 100 71 1.49 3 0.43

≥14 78 100 81 1.28 5 0.24
≥15 85 100 87 1.18 8 0.15
≥16 77 94 92 1.41 12.5 0.11
≥17 69 97 93 1.52 14.29 0.11
Eckardt tool
≥2 59 100 64 1.69 3 0.61
≥3 81 92 83 1.37 6 0.23
≥4 96 85 94 1.23 17 0.07
≥5 54 100 94 1.85 17 0.11

A lower number needed to diagnose is associated with better performance of the test and a higher number needed to misdiagnose is associated
with a better performance of the test. For the likelihood to be diagnosed or misdiagnosed, a smaller number means better performance for
the test. Bold numbers represent best cutoff values and results.

DISCUSSION of failures correctly resulting in the number needed to

diagnose of 1.37 (see Table 3). A cutoff ≥4 identified
There are several important findings from our study. 96% of successes and 85% of failures with a number
To our knowledge, this is the first study to validate needed to diagnose of 1.23 indicating a higher accu-
the Eckardt tool. The results show that the Eckardt racy compared with a cutoff ≥3. An Eckardt score
symptom score is an accurate tool for evaluating post- of ≥2 or ≥5 resulted in a significantly lower rate in
treatment response in patients with achalasia (AUC identifying treatment successes accurately.
0.96 and accuracy of 94%). Despite the prevalent use Our results show that the ASQ questionnaire,
of the Eckardt tool in practice and research, including which is a validated tool, has similar performance
the most recent use in a landmark study,10 it is indeed as the Eckardt tool (AUC 0.97 and 87% accuracy).
surprising that it has not been validated. Another Although the ASQ questionnaire is validated, a cutoff
interesting finding of our study relates to the accu- for assessing success and failures post-treatment has
racy associated with a cutoff ≥3 (traditional value) not been established. We found that a ≥ 15 cutoff
versus ≥4, which is not in line with the established was associated with correctly identifying 85% of
recommendations. For example, using a cutoff ≥3 was the successes and 100% of failures with a number
associated with identifying 81% of successes and 92% needed to diagnose of 1.18. In contrast, a ≥14 cutoff
8 Diseases of the Esophagus

correctly identified 78% of successes and 100% of scores to determine the magnitude of change that
failures resulting in number needed to diagnose of the treatments may have afforded; therefore, we are
1.28. Furthermore, a cutoff ≥16 added little and had unable to determine the responsiveness (sensitivity to
a higher misdiagnosis rate for treatment successes. change) of these instruments.
Another novel finding is the direct comparison of
the ASQ questionnaire with the Eckardt tool, which CONCLUSIONS
is important for clinicians and patients to make an
informed choice. The results show that both tools In conclusion, the findings from our study provide
have similar accuracy but with different tradeoffs. The real-world evidence on the accuracy and performance
overall accuracy of the ASQ questionnaire with a ≥ 15 of the Eckardt and ASQ questionnaires. The evidence
cutoff was 87% versus 94% with the Eckardt tool ≥4 provides physicians and patients with a choice of
cutoff. The number needed to misdiagnose (similar tools in assessing post-treatment response and would
to number needed to harm; higher the number better be helpful in promoting shared decision-making.

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the tool) was 8 for the ASQ questionnaire versus The results reassure physicians that the Eckardt
17 for the Eckardt tool (see Table 3). The choice of and ASQ symptom severity scores are appropriate
either tool is also supported by the strong correlation instruments to assess treatment outcomes in achalasia
(correlation coefficient of 0.85). The results showed patients after PD or surgical myotomy. Importantly,
similar performance when analyzed according to the our study in 106 treated achalasia patients, equally
treatment modality of surgery versus PD. We also divided between PD and myotomy, gives us increas-
observed a discordance between the results of ASQ ing confidence that questionnaires can allow us
and Eckardt tool that we believe is most likely due to to accurately discriminate successes from failures
the different structures of the two tools (Table 1A and with either tool in long-term follow-up for up to
B). The ASQ tool is weighted toward dysphagia with 7 years. This would potentially allow us to reserve
five questions (total max points 16) for this domain. physiological testing (HRM, EndoFLIP, pH testing)
The 11 treatment successes had higher scores for these for patients failing validated questionnaires along
five questions and favorable low scores on questions with clinical presentation rather than performing
9 and 10 addressing global satisfaction. In contrast, them routinely as part of a long-term follow-up
the four question Eckardt tool is not overweighted to program. Our program supports and strengthens
dysphagia (max score 3 of 12) and thus is a better the 2018 International Society for Diseases of the
predictor of treatment success (Table 3). The ASQ, Esophagus recommendation that the Eckardt score
on the other hand, appears to be better in defining and now the ASQ be recommended in the initial and
treatment failures (Table 3). Nevertheless, the results follow-up assessment of all achalasia patients.5
provide evidence for both predictive and convergent
validity of the Eckardt and ASQ tools.
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