Background Acute gastrointestinal injury (AGI) is common in sepsis and is associated with multiple organ dysfunction and poor outcomes. Conventional supportive strategies often fail to restore gastrointestinal motility or adequately modulate systemic inflammation, underscoring the need for safe adjunctive interventions in critically ill patients. Methods We conducted a systematic review and meta-analysis with an exploratory Bayesian network meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Randomized controlled trials and observational cohort studies enrolling adult patients with sepsis-associated gastrointestinal dysfunction were included. Acupuncture (electroacupuncture or manual acupuncture) as an adjunct to standard Western medical care was compared with standard care alone. No restrictions were applied to outcomes during the search phase. Risk of bias was assessed using the revised Cochrane Risk of Bias tool, version 2 (RoB 2) for randomized trials and the Risk of Bias in Non-randomized Studies of Interventions, Version 2 (ROBINS-I V2) for the non-randomized study. Pooled effect estimates were calculated using fixed- or random-effects models, with heterogeneity, publication bias, and sensitivity analyses (leave-one-out) assessed. An exploratory Bayesian network meta-analysis was also performed to compare electroacupuncture and manual acupuncture. Results Twenty studies (19 randomized controlled trials and one retrospective cohort; n = 1, 502) published between 2013 and 2025 were included. Adjunctive acupuncture was associated with improvements in gastrointestinal and physiological parameters, including reduced intra-abdominal pressure, lower Acute Physiology and Chronic Health Evaluation (APACHE) II scores, and increased bowel sounds. Procalcitonin was significantly reduced, while C-reactive protein and white blood cell count did not show statistically significant differences; heterogeneity was substantial for these inflammatory biomarkers. No statistically significant reduction in 28-day mortality was observed. The exploratory network meta-analysis did not detect convincing evidence of superiority between electroacupuncture and manual acupuncture. Reported adverse events were rare and mild. Conclusion Current evidence suggests that acupuncture, when used as an adjunct to standard care, may improve gastrointestinal function and inflammatory profiles in patients with sepsis-associated AGI, but does not confer a clear survival benefit. Given methodological limitations and substantial heterogeneity, well-designed multicenter trials with rigorous controls and clinically relevant endpoints are warranted. Systematic review registration https: //www. crd. york. ac. uk/prospero/displayᵣecord. php? ID=CRD42024530297, Identifier CRD42024530297.
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