Diseases information. Disorders. Treatment.

Constitutional symptoms (eg, fatigue, weight loss) suggests underlying chronic disease.
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Gastrointestinal symptoms

Anorexia, nausea and vomiting are commonly associated with acute abdominal disorders. The frequency, character, and timing of these symptoms in relation to pain and time of the last flatus or stool should be determined.
Constipation, obstipation, crampy pain and distention usually predominate in distal small-bowel and colonic obstruction. Paralytic ileus causes constipation and distention.
Diarrhea is suggestive of gastroenteritis or colitis but may also be seen in partial small-bowel obstruction or fecal impaction.
Small amounts of bleeding may accompany esophagitis, diverticulitis, inflammatory bowel disease, and left colon cancer. Right colon cancers usually present with occult blood loss. Severe abdominal pain accompanied by melena or hematochezia suggests ischemic bowel. Pain is often absent in massive GI bleeding.
Jaundice with abdominal pain usually is caused by biliary stones. Obstruction of the common bile duct by cancer may also cause pain and jaundice.
Urinary symptoms. Urinary tract infections may cause pain in the lower abdomen (cystitis) or flanks (pyelonephritis). Urinary tract infections are characterized by dysuria, frequency, and cloudy urine.
Recent menstrual and sexual history should be determined in women with acute abdominal pain.

Menstrual cycle. Lower abdominal pain and recent amenorrhea in a young woman suggests ectopic pregnancy. Pelvic inflammatory disease tends to occur early in the menstrual cycle. Ovarian torsion may cause intense, acute pain and vomiting. A ruptured corpus luteum cyst may cause acute lower abdominal pain at the onset of menses. Chronic pain at the onset of menses suggests endometriosis.
Pregnancy. Ectopic pregnancy occurs in the first trimester. Threatened abortion, ovarian torsion, or degeneration of a uterine fibroid also may cause acute pain in pregnant women.

Clinical evaluation of abdominal pain

Onset and duration of the pain

The duration, acuity, and progression of pain should be assessed, and the exact location of maximal pain at onset and at present should be determined. The pain should be characterized as diffuse or localized. Time course of pain should be characterized as either constant, intermittent, decreasing, or increasing.

Acute exacerbation of longstanding pain suggests a complication of chronic disease such as peptic ulcer disease, inflammatory bowel disease, or cancer. Sudden, intense pain often represents an intraabdominal catastrophe (eg, ruptured aneurysm, mesenteric infarction, or intestinal perforation). Colicky abdominal pain of intestinal or ureteral obstruction tends to have a gradual onset.

Pain character

Intermittent pain is associated with spasmodic increases in pressure within hollow organs.

Bowel ischemia initially causes diffuse crampy pain due to spasmodic contractions of the bowel. The pain becomes constant and more intense with bowel necrosis, causing pain out of proportion to physical findings. A history of intestinal angina can be elicited in half of patients.

Constant pain. Biliary colic from cystic or common bile duct obstruction usually is constant. Chronic pancreatitis causes constant pain. Constant pain also suggests parietal peritoneal inflammation, mucosal inflammatory conditions, or neoplasms.
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Appendicitis initially causes intermittent periumbilical pain. Gradually the pain becomes constant in the right lower quadrant as peritoneal inflammation develops.

 3. What is known about the biological effects of acupuncture that helps us understand how it works?
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Many studies in animals and humans have demonstrated that acupuncture can cause multiple biological responses. These responses can occur locally, i.e., at or close to the site of application, or at a distance, mediated mainly by sensory neurons to many structures within the central nervous system. This can lead to activation of pathways affecting various physiological systems in the brain as well as in the periphery. A focus of attention has been the role of endogenous opioids in acupuncture analgesia. Considerable evidence supports the claim that opioid peptides are released during acupuncture and that the analgesic effects of acupuncture are at least partially explained by their actions. That opioid antagonists such as naloxone reverse the analgesic effects of acupuncture further strengthens this hypothesis. Stimulation by acupuncture may also activate the hypothalamus and the pituitary gland, resulting in a broad spectrum of systemic effects. Alteration in the secretion of neurotransmitters and neurohormones and changes in the regulation of blood flow, both centrally and peripherally, have been documented. There is also evidence that there are alterations in immune functions produced by acupuncture. Which of these and other physiological changes mediate clinical effects is at present unclear.
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Despite considerable efforts to understand the anatomy and physiology of the “acupuncture points,” the definition and characterization of these points remains controversial. Even more elusive is the scientific basis of some of the key traditional Eastern medical concepts such as the circulation of Qi, the meridian system, and other related theories, which are difficult to reconcile with contemporary biomedical information but continue to play an important role in the evaluation of patients and the formulation of treatment in acupuncture.
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Some of the biological effects of acupuncture have also been observed when “sham” acupuncture points are stimulated, highlighting the importance of defining appropriate control groups in assessing biological changes purported to be due to acupuncture. Such findings raise questions regarding the specificity of these biological changes. In addition, similar biological alterations including the release of endogenous opioids and changes in blood pressure have been observed after painful stimuli, vigorous exercise, and/or relaxation training; it is at present unclear to what extent acupuncture shares similar biological mechanisms.
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It should be noted also that for any therapeutic intervention, including acupuncture, the so-called “non-specific” effects account for a substantial proportion of its effectiveness, and thus should not be casually discounted. Many factors may profoundly determine therapeutic outcome including the quality of the relationship between the clinician and the patient, the degree of trust, the expectations of the patient, the compatibility of the backgrounds and belief systems of the clinician and the patient, as well as a myriad of factors that together define the therapeutic milieu.

Although much remains unknown regarding the mechanism(s) that might mediate the therapeutic effect of acupuncture, the panel is encouraged that a number of significant acupuncture-related biological changes can be identified and carefully delineated. Further research in this direction not only is important for elucidating the phenomena associated with acupuncture, but also has the potential for exploring new pathways in human physiology not previously examined in a systematic manner.
Conclusions and Recommendations

Acupuncture as a therapeutic intervention is widely practiced in the United States. There have been many studies of its potential usefulness. Promising results have emerged, for example, efficacy of acupuncture in adult post-operative and chemotherapy nausea and vomiting and in post-operative dental pain. There are other situations such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma where acupuncture may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program.

Findings from basic research have begun to elucidate the mechanisms of action of acupuncture, including the release of opioids and other peptides in the central nervous system and the periphery and changes in neuroendocrine function.

2. What is the place of acupuncture in the treatment of various conditions for which sufficient data are available, in comparison with or in combination with other interventions (including no intervention)?
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Assessing the usefulness of a medical intervention in practice differs from assessing formal efficacy. In conventional practice, clinicians make decisions based on the characteristics of the patient, clinical experience, potential for harm, and information from colleagues and the medical literature. In addition, when more than one treatment is possible, the clinician may make the choice taking into account the patient’s preferences. While it is often thought that there is substantial research evidence to support conventional medical practices, this is frequently not the case. This does not mean that these treatments are ineffective. The data in support of acupuncture are as strong as those for many accepted Western medical therapies.
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One of the advantages of acupuncture is that the incidence of adverse effects is substantially lower than that of many drugs or other accepted medical procedures used for the same conditions. As an example, musculoskeletal conditions, such as fibromyalgia, myofascial pain, and “tennis elbow,” or epicondylitis, are conditions for which acupuncture may be beneficial. These painful conditions are often treated with, among other things, anti-inflammatory medications (aspirin, ibuprofen, etc.) or with steroid injections. Both medical interventions have a potential for deleterious side effects, but are still widely used, and are considered acceptable treatments. The evidence supporting these therapies is no better than that for acupuncture.
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In addition, ample clinical experience, supported by some research data, suggests that acupuncture may be a reasonable option for a number of clinical conditions. Examples are postoperative pain and myofascial and low back pain. Examples of disorders for which the research evidence is less convincing but for which there are some positive clinical trials include addiction, stroke rehabilitation, carpal tunnel syndrome, osteoarthritis, and headache. Acupuncture treatment for many conditions such as asthma or addiction should be part of a comprehensive management program.

Many other conditions have been treated by acupuncture; the World Health Organization, for example, has listed more than 40 for which the technique may be indicated.

1. What is the efficacy of acupuncture, compared with placebo or sham acupuncture, in the conditions for which sufficient data are available to evaluate?
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Acupuncture is a complex intervention that may vary for different patients with similar chief complaints. The number and length of treatments and the specific points used may vary among individuals and during the course of treatment. Given this reality, it is perhaps encouraging that there exist a number of studies of sufficient quality to assess the efficacy of acupuncture for certain conditions.
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According to contemporary research standards, there is a paucity of high-quality research assessing efficacy of acupuncture compared with placebo or sham acupuncture. The vast majority of papers studying acupuncture in the biomedical literature consist of case reports, case series, or intervention studies with designs inadequate to assess efficacy.
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This discussion of efficacy refers to needle acupuncture (manual or electroacupuncture) because the published research is primarily on needle acupuncture and often does not encompass the full breadth of acupuncture techniques and practices. The controlled trials usually have only involved adults and did not involve long-term (i.e., years) acupuncture treatment.

Efficacy of a treatment assesses the differential effect of a treatment when compared with placebo or another treatment modality using a double-blind controlled trial and a rigidly defined protocol. Papers should describe enrollment procedures, eligibility criteria, description of the clinical characteristics of the subjects, methods for diagnosis, and a description of the protocol (i.e., randomization method, specific definition of treatment, and control conditions, including length of treatment, and number of acupuncture sessions). Optimal trials should also use standardized outcomes and appropriate statistical analyses. This assessment of efficacy focuses on high-quality trials comparing acupuncture with sham acupuncture or placebo.

Response Rate. As with other types of interventions, some individuals are poor responders to specific acupuncture protocols. Both animal and human laboratory and clinical experience suggest that the majority of subjects respond to acupuncture, with a minority not responding. Some of the clinical research outcomes, however, suggest that a larger percentage may not respond. The reason for this paradox is unclear and may reflect the current state of the research.
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Efficacy for Specific Disorders. There is clear evidence that needle acupuncture is efficacious for adult postoperative and chemotherapy nausea and vomiting and probably for the nausea of pregnancy.

Much of the research is on various pain problems. There is evidence of efficacy for postoperative dental pain. There are reasonable studies (although sometimes only single studies) showing relief of pain with acupuncture on diverse pain conditions such as menstrual cramps, tennis elbow, and fibromyalgia. This suggests that acupuncture may have a more general effect on pain. However, there are also studies that do not find efficacy for acupuncture in pain.

There is evidence that acupuncture does not demonstrate efficacy for cessation of smoking and may not be efficacious for some other conditions.

While many other conditions have received some attention in the literature and, in fact, the research suggests some exciting potential areas for the use of acupuncture, the quality or quantity of the research evidence is not sufficient to provide firm evidence of efficacy at this time.

Sham Acupuncture. A commonly used control group is sham acupuncture, using techniques that are not intended to stimulate known acupuncture points. However, there is disagreement on correct needle placement. Also, particularly in the studies on pain, sham acupuncture often seems to have either intermediate effects between the placebo and ‘real’ acupuncture points or effects similar to those of the ‘real’ acupuncture points. Placement of a needle in any position elicits a biological response that complicates the interpretation of studies involving sham acupuncture. Thus, there is substantial controversy over the use of sham acupuncture as control groups. This may be less of a problem in studies not involving pain.

To address important issues regarding acupuncture, the NIH Office of Alternative Medicine and the NIH Office of Medical Applications of Research organized a 21 /2 -day conference to evaluate the scientific and medical data on the uses, risks, and benefits of acupuncture procedures for a variety of conditions. Cosponsors of the conference were the National Cancer Institute, the National Heart, Lung, and Blood Institute, the National Institute of Allergy and Infectious Diseases, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the National Institute of Dental Research, the National Institute on Drug Abuse, and the Office of Research on Women’s Health of the NIH. The conference brought together national and international experts in the fields of acupuncture, pain, psychology, psychiatry, physical medicine and rehabilitation, drug abuse, family practice, internal medicine, health policy, epidemiology, statistics, physiology, and biophysics, as well as representatives from the public.

After 11 /2 days of available presentations and audience discussion, an independent, non-Federal consensus panel weighed the scientific evidence and wrote a draft statement that was presented to the audience on the third day.