Acupuncture Instantly Relieves Right Upper Abdominal Pain in Acute Cholecystitis Patients ()
1. Introduction
Gallstones blocking the flow of bile in the biliary tree, leading to inflammation of the gallbladder, result in cholecystitis. Acute calculous cholecystitis (ACC) is one of the most common surgical emergencies worldwide and represents a significant complication of cholelithiasis (gallstone disease). Prompt diagnosis and appropriate management are crucial to prevent serious complications such as gallbladder perforation, peritonitis, or sepsis.
Acute calculous cholecystitis is a common surgical condition requiring a multidisciplinary approach. Ultrasound is diagnostic, and laparoscopic cholecystectomy remains the cornerstone of curative treatment. Tailored management based on severity and patient comorbidities is essential for optimal outcomes.
Right upper abdominal pain is the common symptom of acute cholecystitis and is generally the cause for patients to seek medical treatment [1]. The severity of cholecystitis can be estimated according to measurements of white blood cell counts, fever, and swelling of the gallbladder [2]. Although for most acute cholecystitis the definitive treatment is laparoscopic cholecystectomy, some patients are scared of undergoing surgery unless their clinical manifestations worsen [3]. Thus, pain relief is essential in these patients.
The conventional clinical treatments for pain are physiotherapy, corticosteroid injections, surgery, and analgesic medication . Clinically, anisodamine injections may partially suppress right upper abdominal pain in acute cholecystitis patients, though its side effects are concerning. As an effective treatment for acute or chronic pain, acupuncture has received considerable attention around the world [4]-[6].
An acupoint is the basic element related to acupuncture. Yanglingquan (GB34) and Zusanli (ST36) are both specific acupoints related to biliary functions. Stimulating each of the two points is considered to ameliorate symptoms of some biliary diseases, especially in the relief of upper abdominal pain [7] [8]. We tried needling both of the acupoints in order to get a more apparent pain-relief effect in acute cholecystitis patients, using a visual analogue scale (VAS) to quantify pain.
2. Materials and Methods
2.1. Patients and Design
Inpatients in our surgical ward diagnosed with acute calculous cholecystitis between January 2022 and February 2025 were enrolled in our study. The sample size for this study was calculated using General Power Analysis software. Based on the McNemar test, with a significance level of α = 0.05 (two-tailed), a test power of 0.8, and an expected discordant pair proportion of 0.3, the minimum required sample size was determined to be 62 subjects. Accounting for an estimated dropout rate of 10%, we ultimately planned to enroll 81 patients. Since the majority of patients require surgical treatment, while our study focused on those receiving conservative management, the timeline for collecting sufficient cases was consequently extended.
All patients presented with right upper abdominal pain and accepted acupuncture to relieve pain before other medical treatments. Their white blood cell counts and amylase levels in blood and urine were examined to confirm the diagnosis or to exclude acute pancreatitis. Acupuncture was not performed in patients who presented with evidence of acute obstructive suppurative cholangitis. Patients with severe cardiovascular or pulmonary dysfunction and/or suffering from medical or psychiatric disorders were also excluded from our acupuncture intervention. The acupuncture needles used in this study, with a diameter of 0.25 mm and a length of 75 mm, were stainless steel and disposable.
2.2. Needling and Score
Prior to needling, patients were made clear that a score of zero on the VAS scale would be the equivalent of no pain and a score of 10 represented the present pain. The patient was kept in a supine position, and the areas of two acupoints on both lower limbs were sterilized with 75% alcohol. Needling was performed bilaterally. Acupoint Yanglingquan was located lateral to the shank and in the depression anterior and inferior to the head of the fibula. The location of Zusanli is superior and lateral to the shank, in the depression about 6 cm directly below the small head of the fibula, or the tender point around 6 cm directly below Yanglingquan. (Figure 1). To ensure accurate acupoint localization, manual palpation could be performed prior to needling, with the tenderness point (characterized by soreness and distension) indicating the optimal insertion site. Needles were perpendicularly inserted at an approximate depth of 2 cm, following a rapid lifting, thrusting, and twirling until the patient felt soreness and pain, and were then retained for twenty minutes before withdrawal. All patients were informed to specify the level of pain by indicating a position along the VAS scale after removal of the needles. A VAS score of less than 6 (score 6 was not included, i.e., pain reduced by half) after needling was regarded as effective, and data were collected for analysis.
![]()
Figure 1. Localization of the acupoints Yanglingquan and Zusanli.
3. Statistical Analysis
Demographic, clinical, and pain characteristics of patients were analyzed descriptively. For categorical variables, absolute and relative frequencies were presented using histograms. Data were assessed with Q-Q Plots for normal distribution, calculating 95% confidence intervals. Distributions of gender, age, and clinical variables of categorical nature were compared between groups using the Pearson chi-square test. Statistical tests were two-sided. The IBM SPSS Statistics version 17 was used, and p < 0.05 was considered statistically significant.
4. Results
4.1. VAS Score Distribution
A total of 81 patients aged 23 to 72 were enrolled. All participants tolerated the needling procedures without adverse events. Acupuncture is a widely recognized and accepted modality for pain management in China. No patients in our study refused acupuncture treatment. Our observations confirmed that all participants tolerated the procedure well, with no acupuncture-related adverse effects reported. The VAS scores were categorized, and the distribution was normal (Figure 2). Sixty patients graded their pain as less than score 6 after the withdrawal of needles (efficacy 60/81 = 74.07%, 95% CI 64.53% - 83.62%) (Figure 3).
4.2. Clinical Characteristics and Pain Relief Effect
Table 1 presents clinical characteristics of the patients. There were 33 male patients and 48 female patients; the number of patients with increased WBC counts of more than 1.5 × 109/L was 25; 62 patients had onset of abdominal pain for more than 3 hours; diabetes was concomitant in 9 patients and 60 patients were
Figure 2. Normal distribution of VAS score.
Figure 3. Histogram of score distribution.
Table 1. Clinical and characteristics, pain relief effects of the patients.
|
Total (n = 81) |
Effective (n = 60) |
p value |
Gender |
|
|
0.456 |
Male |
33 |
23 (69.70%) |
Female |
48 |
37 (77.08%) |
Age |
|
|
0.46 |
<60 y |
59 |
45 (76.27%) |
>60 y |
22 |
15 (68.18%) |
WBC counts |
|
|
0.167 |
<1.5 × 109/L |
56 |
44 (78.57%) |
>1.5 × 109/L |
25 |
16 (64.00%) |
Time of onset |
|
|
0.58 |
<3 h |
19 |
15 (78.95%) |
>3 h |
62 |
45 (72.58%) |
|
Diabetes |
|
|
0.179 |
Yes |
9 |
5 (55.56%) |
No |
72 |
55 (76.39%) |
Recurrence |
|
|
0.403 |
Yes |
60 |
43 (71.67%) |
No |
21 |
17 (80.95%) |
Total = number of all patients enrolled; Effective = number of patients with a VAS score less than 6; p < 0.05 = statistical significance (chi-square test).
diagnosed with recurrent cholecystitis.
In all 81 patients, most felt a reduction in pain level after needling, and some even claimed that their pain had disappeared during needling. Statistically, the effect of pain relief after acupuncture was irrelevant to gender, age, time of onset, diabetes, and recurrence of cholecystitis (p > 0.05). The pain relief effect of acupuncture was also not prominent in patients with WBC counts more than 1.5 × 109/L, as compared with the lower WBC patients (p = 0.167).
5. Discussion
Acute calculus cholecystitis is a commonly encountered disease and usually needs surgical treatment, such as laparoscopic cholecystectomy [2] [3]. Besides fever and increased white blood cell counts, most patients present with right upper abdominal pain due to blockage of the cystic duct by gallstones [1] [2]. Timely and correct pain relief may minimize patients’ distress and result in faster recovery.
As a Chinese traditional treatment for different kinds of pain, acupuncture has been getting popular around the world, even in anesthesia during surgery [9]. Though the mechanism remains unclear, its efficacy against pain has been supported by various methods of testing [10].
According to the theory of traditional Chinese medicine, all parts of the body are connected through the meridian system. The gallbladder meridian of foot-shaoyang is one part of the meridian system and is composed of three branches. Acupoint Yanglingquan is located on the second branch, which links with the liver and enters the gallbladder, and is believed to be related to hypochondriac pain, jaundice, and pain in the loins and legs [7]. The Zusanli acupoint is an extraordinary acupoint that does not pertain to any meridian but can relieve symptoms of cholecystitis, biliary ascariasis, and flaccidity of the lower limbs when needled [8].
Concerning the relationship of the two acupoints with the biliary system, we simultaneously needled them in order to verify pain-suppressing results in acute cholecystitis patients. The results showed that most patients got pain relief according to VAS measurements after needling for 20 min, and the efficacy reached 74.07% (60/81) if a VAS score of less than 6 was used for calculation. We found that the pain relief effect had no relationship with gender, age, concomitance of diabetes, or recurrence of cholecystitis and was not significantly different between patients with severe or light gall bladder inflammation.
Accurately locating acupoints was important and a prerequisite to treatment [11]. To locate Yanglingquan, the first step was to locate the head of the fibula, which is an apparent anatomical landmark. Then, find a depressed area below and lateral to this bone signifier. Acupoint Zusanli is the point near 6 cm directly below Yanglingquan. If the patient felt pain or tenderness after the acupuncturist’s finger pressing on the two sites, the locations of Yanglingquan and Zusanli might be accurately confirmed.
Though variability exists between acupuncture practitioners, twirling-rotating and lifting-thrusting are the two basic manipulations that can be used individually or in combination [12] [13]. The amplitude of twirling and the scope of lifting-thrusting, as well as the frequency and duration of manipulation, depend upon the patient’s constitution and pathological conditions. A patient sensing aching, numbness, heaviness, or distension at the needling point usually means a good manipulation. Acupuncture sensation may play an important role in verifying the effect of acupuncture [14]. Retaining the needles for 20 min may strengthen the pain-relief effect.
The effect of reducing right upper abdominal pain by simultaneously needling in the acupoints Yanglingquan and Zusanli was apparent. However, acupuncture was not a treatment to inhibit inflammation. Acute cholecystitis patients need further medication if presenting with progressing pain, elevated white blood cell counts, and fever [2]. But needling the two acupoints was a safe and applicable means to relieve right upper abdominal pain. Acupuncture, as an adjunctive analgesic therapy for acute cholecystitis, demonstrates effective symptom control, a favorable safety profile with minimal complications, and the capacity to optimize preoperative patient condition.
Ethical Approval
Approved (approval number 22012506) by Institutional Review Board of Pudong New District Hospital of Traditional Chinese Medicine, affiliated to Shanghai University of Traditional Chinese Medicine.
Contributors
Jianming Zhu designed the study, conducted the analyses, data interpretation, and manuscript production. Jianping Huang promoted and guided the study and approved the final submitted manuscript.
Acknowledgments
The authors are thankful to all research participants for supporting this project.