ABSTRACT Background and Aim Achalasia's insidious onset and nonspecific presentation contribute to diagnostic delays, often exceeding 20 months from symptom onset to confirmation. The four‐domain CARS endoscopic score (Content, Anatomy, Resistance, Stasis) may expedite risk stratification. We performed a meta‐analysis to assess diagnostic accuracy, interobserver reliability, and treatment‐monitoring potential. Methods We searched PubMed, Embase, Web of Science, the Cochrane Library, and ClinicalTrials.gov through June 2025. Study‐level 2 × 2 contingency data were then synthesized using bivariate random‐effects models to derive pooled sensitivity, specificity, positive predictive value, and negative predictive value, generate HSROC curves, and construct Fagan nomograms at 5% and 25% pre‐test probabilities. Results We screened 49 studies and ultimately included five studies encompassing 1112 patients with a mean age of 54.5 years and overall achalasia prevalence of 31.7%. For a CARS threshold ≥ 4, pooled sensitivity was 0.73 (95% CI 0.69–0.78), specificity 1.00 (0.99–1.00), positive predictive value 0.99, and negative predictive value 0.88; employing a dual‐threshold strategy (CARS = 0 to rule out; ≥ 4 to rule in) further improved sensitivity to 0.95 (0.92–0.98), specificity to 0.99 (0.97–1.00), positive predictive value to 0.99, and negative predictive value to 0.96. The HSROC AUC approached 0.99, and moreover interobserver agreement was almost perfect with a pooled Cohen's κ = 0.84 (95% CI 0.76–0.91). Conclusions CARS reliably stratifies patients into low‐risk (CARS = 0), moderate‐risk (1–3), and high‐risk (≥ 4) groups facilitating deferred testing, targeted manometry, or prompt invasive evaluation while demonstrating excellent interobserver agreement, underscoring its clinical utility. Trial Registration PROSPERO number: CRD420251007005
Amdetsion et al. (Thu,) studied this question.
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