Therapeutic effects of rhubarb enema on Th17 cell and systemic inflammatory response in clinical acute pancreatitis

Abstract

BACKGROUND

Acute pancreatitis (AP) is a common disease in the intensive care unit. Although the clinical management of AP has improved, over mortality has not declined significantly. Rhubarb, an anthraquinone glycoside derivative, has been reported to improve intestinal blood perfusion, inhibit excessive inflammatory responses, regulate inflammatory mediator cascades, and enhance intestinal motility.

AIM

To investigate the effects of rhubarb on prognosis and complications in patients with AP.

METHODS

A total of 284 patients with AP meeting the inclusion criteria will be randomly assigned in a 1:1 ratio to receive either rhubarb enema therapy or placebo (saline) for a 7-day treatment course. The primary outcome is the 28-day mortality rate. Secondary outcomes include serum levels of tumor necrosis factor-alpha (TNF-α), interleukin (IL)-1β, IL-6, IL-8, IL-10, IL-17A, and CXCL1 measured at 1 day, 3 days, 5 days, and 7 days after hospital admission.

RESULTS

Our research results show that rhubarb enema treatment can significantly improve the systemic inflammatory response in patients with AP, and reduce the inflammatory cytokines or chemokines (e.g., TNF-α, IL-1β, IL-6, IL-8, IL-17A, and CXCL-1). Moreover, it can improve the patient’s inflammatory immune state and reduce the proportion of Th17 cells. The primary end point death failure was observed in 2 (1.39%) of 144 patients in the Rhubarb group and in 4 (2.86%) of 140 patients in the control group, with no difference in mortality or major complications between the groups.

CONCLUSION

Rhubarb enema treatment significantly reduced intra-abdominal hypertension, decreased the incidence of deep venous thrombosis, and reduced the need for intervention. These findings suggest that rhubarb enema therapy can significantly improve clinical outcomes of AP, potentially through the inhibition of inflammatory responses, thus providing a tool for anti-AP therapy.

Key Words: Acute pancreatitis; Rhubarb; T helper 17; Inflammation; Cytokines

Core Tip: Acute pancreatitis (AP) is a disease with high mortality, caused by the activation of pancreatic enzymes due to multiple factors and characterized by localized pancreatic inflammation. Pharmacological studies indicate that rhubarb significantly improves intestinal blood perfusion, suppresses excessive inflammatory responses, modulates inflammatory mediator cascades, and enhances intestinal motility. However, whether rhubarb improves the prognosis and complications in patients with AP by inhibiting Th17 cell differentiation and inflammatory responses remains unclear. Therefore, this study was conducted to evaluate the role of rhubarb in patients with AP.

INTRODUCTION

Acute pancreatitis (AP) is a disease characterized by pancreatic enzyme activation induced by various factors, followed by a localized inflammatory response in the pancreas, and is associated with high case fatality rates[1]. Approximately 15%-20% of patients develop severe AP accompanied by persistent organ dysfunction and systemic complications[2], resulting in significantly increased mortality rates. Although advances in clinical management have been achieved, there has been no significant reduction in AP-induced mortality[3]. The cascade of inflammatory mediators represents a central mechanism driving the systemic pathophysiological process of AP directly or indirectly[4]. The activation and recruitment of inflammatory cells trigger multiple inflammatory signaling pathways, amplifying the inflammation cascade[5]. Cytokines are essential in initiating, amplifying, and maintaining uncontrolled inflammatory responses in AP[6,7]. Previous studies have shown that reducing vascular permeability, inhibiting inflammatory cytokine expression, and removing endotoxins can effectively improve prognosis in patients with AP[8]. Therefore, effective blockade of systemic inflammatory responses remains an important target in the management of AP.

T lymphocytes are important in the immune responses during AP[9]. Th17 cells are considered strong inducers of tissue inflammation due to their capacity to produce and secrete large amounts of the proinflammatory cytokine interleukin (IL)-17A[10]. During the early stages of AP, excessive activation of immune cells such as Th17 leads to the overproduction of proinflammatory cytokines, leading to multiorgan dysfunction in patients[11].

The main components of rhubarb are anthraquinones, anthrones, and dianthrones, including lutein, lutein, and dijanoric acid, with reported anti-inflammatory, antioxidant, hepatoprotective, vasodilatory, diuretic, antiviral, and anti-tumor properties[12]. Pharmacological studies have shown that rhubarb significantly improves intestinal blood perfusion, inhibits excessive inflammatory responses, regulates inflammatory mediator cascades, and enhances intestinal motility[13]. Additionally, rhubarb may enhance patient immunity by improving neutrophil phagocytosis and reducing complement levels[14]. However, to date, no studies have investigated whether rhubarb can improve the prognosis and complications in patients with AP by inhibiting Th17 cell differentiation and inflammatory responses. Therefore, this clinical study was conducted to evaluate the role of rhubarb in patients with AP.

MATERIALS AND METHODS

Sample size calculation

The sample size for this prospective randomized controlled trial was calculated based on the primary endpoint of 28-day all-cause mortality. The anticipated 28-day mortality rate in the standard therapy (control) group was assumed to be 35% (P₂ = 0.35), based on historical data from previous studies. It was hypothesized that adjunctive rhubarb enema therapy (intervention group) would result in a relative mortality reduction of approximately 43%, corresponding to an expected mortality rate of 20% (P₁ = 0.20).

The two-sided Z value for a type I error (α) was set at 1.96 (α = 0.05), and the Z value for a type II error (β) was set at 0.842, corresponding to a statistical power of 80%.

Based on these assumptions, the calculated sample size was approximately 138 participants per group. All calculations were performed using Power Analysis and Sample Size software, version 2021 (NCSS, LLC).

Ethical considerations

This study was designed and conducted in accordance with the Declaration of Helsinki and the International Council for Harmonization Guideline for Good Clinical Practice.

Ethical approval: Prior to study initiation, the complete study protocol, informed consent form (ICF), and all participant-related materials reviewed and approved by the Institutional Review Board (IRB)/Independent Ethics Committee (IEC) of the First Affiliated Hospital of Chongqing Medical University (Approval No. 2022-077). Any subsequent protocol amendments required re-approval by the IRB/IEC before implementation.

Informed consent: Participation in this study is entirely voluntary. Written ICFs was obtained from all participants or their legally authorized representatives (LARs) before enrollment and initiation of any study-specific procedures. The consent process was conducted by qualified investigators who was explained the study objectives, procedures, potential risks and benefits, alternative treatments, and the right to withdraw at any time without affecting standard care. Participants or their LARs were given sufficient time to consider participation and ask questions. A signed and dated copy of the ICF was provided to each participant.

Data confidentiality and privacy: To ensure confidentiality, all personal data were de-identified and replaced with unique coded identifiers for data collection and analysis. Study documents containing personal information were stored securely in locked cabinets or on password-protected, encrypted servers, with access restricted to authorized study personnel only. Participant confidentiality was maintained in accordance with applicable local data protection laws and regulations.

Randomization and blinding: Patients were randomly assigned to the treatment or control groups within 24 hours of enrollment. Randomization sequences were generated using SAS version 9.4 (SAS Institute, United States) and sealed in sequentially numbered opaque envelopes. Each envelope contained treatment allocation information corresponding to either rhubarb or saline. All study participants, except for the unblinded drug-preparing nurses (UDPNs), remained blinded to the randomization information. The UDPN opened the envelope, prepared a 50-mL syringe containing either rhubarb solution or normal saline, and handed the opaque syringe to the treatment nurse. The UDPN did not participate in subsequent procedures. Outcome assessors and statisticians were blinded to the randomization and did not participate in the treatment administration.

Trial registration: This trial was prospectively registered in the Chinese Clinical Trial Registry with the registration number ChiCTR2100046548.

Human study subjects

A total of 284 patients with AP admitted to the intensive care unit (ICU) or Department of Gastroenterology of the First Affiliated Hospital of Chongqing Medical University between April 2022 and December 2024 were enrolled. AP was diagnosed according to the Revised Atlanta Classification (2012) based on the presence of at least two of the following criteria: (1) Acute onset of abdominal pain, often radiating to the back; (2) Serum amylase or lipase levels ≥ times the upper limit of normal; and (3) Imaging findings consistent with AP[15]. Exclusion criteria included any of the following: (1) Age < 18 years or > 80 years; (2) Surgery performed within three days after admission (severity evaluation period); (3) Pregnancy; (4) Previous or long-term immunosuppressive therapy; (5) Congenital immune dysfunction; (6) History of malignancy or chronic lung, kidney, or cardiovascular disease; and (7) Biliary pancreatitis, traumatic pancreatitis, or chronic pancreatitis. Samples from healthy individuals were collected from donors without known medical conditions at the Medical Examination Center of the First Affiliated Hospital of Chongqing Medical University.

Measurements

Peripheral venous blood samples were collected from each patient at 1 day, 3 days, 5 days, and 7 days after hospital admission and stored at -80 °C until analysis. Peripheral blood lymphocyte subsets (Th17/CD4⁺) were analyzed at the Clinical Testing Center of the First Affiliated Hospital of Chongqing Medical University. Serum levels of tumor necrosis factor-alpha (TNF-α), IL-1β, IL-6, IL-8, IL-10, IL-17A, and CXCL1 were measured using a Human Cytokine/Chemokine Magnetic Bead Panel Kit (Merck Millipore, Germany). Intra-abdominal pressure (IAP) was measured using the transvesical method. Intra-abdominal hypertension was defined according to the International Conference of Experts criteria[16].

Treatments

All patients received standard treatment for AP, including nutritional support, early fluid resuscitation, target organ treatment, and prophylactic antibiotics, according to the British and Chinese Medical Association guidelines. Patients were then randomly divided into two treatment groups: (1) Rhubarb group: In addition to standard treatment, patients received rhubarb enema consisting of 0.3 g/kg rhubarb powder (Gansu Yalan Pharmaceutical Co., Ltd., Gansu Province, China) dissolved in 100 mL normal saline, filtered to remove residue, and heated to 37-38 °C. The enema was administered for more than 15 minutes, twice daily for seven consecutive days[17]; and (2) Control group: In addition to standard treatment, patients received 100 mL normal saline enema administered for more than 15 minutes, twice daily for seven consecutive days.

Statistical analysis

All statistical analyses were performed using the SPSS version 19.0. Data were expressed as means ± SEM. Differences between groups were analyzed using Student’s t-tests. Comparisons among multiple groups were performed using one-way or two-way analysis of variance (ANOVA), followed by post hoc tests (least significant difference or a Dunnett’s test, as appropriate). Spearman’s rank correlation coefficient was used for nonparametric correlation analyses.

RESULTS

Baseline characteristics of the study population

A total of 361 consecutive patients with AP were prospectively registered between April 2022 and December 2024. Of these, 77 patients were excluded, and the remaining 284 patients were randomly assigned to receive either rhubarb or saline intervention. Figure 1 shows a detailed flow chart of the study. Baseline characteristics were comparable between the two groups, as shown in Table 1.

Figure 1  Research flowchart.

Table 1 Baseline patient characteristics.

Characteristics	Rhubarb group (n = 144)	Controls group (n = 140)
Sex (male/female)	80/64	77/63
Age (year)	52 (36-64)	55 (37-52)
Cause of pancreatitis, n (%)
Alcohol abuse	18 (12.5)	13 (9.3)
Hypertriglyceridemia	116 (80.6)	121 (86.4)
Idiopathic	10 (6.9)	6 (4.3)
Disease severity at grouping
BISAP score	2.81 ± 1.71	2.93 ± 1.94
CTSI score	7 (5-8)	6 (5-7)
APACHE II score	17.1 (14.2-22.9)	19.2 (15.3-21.5)
SOFA score	8.4 (6.9-17.2)	7.6 (6.1-16.7)
PaO2/FiO2 (mmHg)	241.63 ± 19.97	223.16 ± 41.67
Other features at grouping
WBC (109/L)	18 (15-22)	17 (13-24)
PCT (ng/mL)	4.27 ± 0.76	3.03 ± 1.09
IAP (cmH2O)	29.31 (21-33)	27.47 (19-36)

Data are expressed as median (interquartile range) or mean ± SEM unless otherwise indicated. APACHE II: Acute physiology and chronic health evaluation II; SOFA: Sequential organ failure assessment; WBC: White blood cells; BISAP: Bedside Index for Severity in Acute Physiology; CTSI: Balthazar Computed Tomography Severity Index; PCT: Procalcitonin; IAP: Intra-abdominal pressure.

Circulating cytokines, chemokines, and Th17 lymphocyte subsets were elevated in patients with AP

Multiple inflammatory mediators are involved in the initiation, amplification, and maintenance of inflammation during AP. In this cohort, 144 patients were assigned to the rhubarb group and 140 patients to the saline (control) group. Serum samples were collected from all patients before treatment. The concentrations of cytokines and chemokine, including TNF-α (rhubarb: 59.07 ± 28.22, control: 46.79 ± 26.71, healthy: 9.19 ± 4.07), IL-1β (rhubarb: 31.96 ± 15.81, control: 36.88 ± 21.64, healthy: 3.95 ± 1.44), IL-6 (rhubarb: 47.55 ± 23.18, control: 48.30 ± 10.61, healthy: 9.26 ± 4.39), IL-8 (rhubarb: 78.05 ± 36.08, control: 87.82 ± 38.77, healthy: 16.49 ± 4.89), IL-10 (rhubarb: 409.22 ± 152.60, control: 404.99 ± 90.62, healthy: 32.68 ± 11.21), IL-17A (rhubarb: 308.87 ± 135.59, control: 375.93 ± 92.21, healthy: 9.99 ± 3.67) and CXCL1 (rhubarb: 384.63 ± 197.71, control: 445.92 ± 233.35, healthy: 35.82 ± 14.43) were significantly higher in both patient groups than in healthy individuals (Figure 2). Furthermore, the proportion of Th17/CD4⁺ lymphocytes in peripheral blood was significantly higher in patients from both groups than in healthy individuals (Figure 2).

Figure 2 Circulating cytokines, chemokine and Th17 lymphocyte subsets were elevated in human acute pancreatitis patients. ^aP < 0.0001. TNF-α: Tumor necrosis factor-alpha; IL: Interleukin; NS: Not significant.

Correlation of cytokines, chemokines, and Th17 cells with disease severity in patients with AP

Correlation analyses were performed to evaluate the associations between circulating cytokines, chemokines, and Th17 lymphocytes, and disease severity. The Balthazar Computed Tomography Severity Index (CTSI) score showed significant positive correlations with IL-6 (r = 0.26, P = 0.02), IL-17A (r = 0.30, P < 0.01), IL-8 (r = 0.42, P < 0.01), TNF-α (r = 0.28, P = 0.01), and Th17 lymphocytes (r = 0.30, P < 0.01). In contrast, CTSI score was significantly negatively correlated with IL-10 (r = -0.26, P < 0.01). Detailed correlation coefficients are shown in Table 2.

Table 2 Correlation coefficients between Balthazar Computed Tomography Severity Index score and cytokines.

	CTSI score	IL-6	IL-17A	TNF-α	IL-8	IL-1β	CXCL-1	Th17	IL-10
CTSI score		0.26 (P = 0.02)	0.30 (P < 0.01)	0.28 (P = 0.01)	0.42 (P < 0.01)	0.12 (P > 0.05)	0.06 (P > 0.05)	0.30 (P < 0.01)	-0.26 (P < 0.01)
IL-6			0.42 (P < 0.01)	0.06 (P > 0.05)	0.05 (P > 0.05)	0.07 (P > 0.05)	-0.11 (P > 0.05)	0.37 (P < 0.01)	-0.34 (P < 0.01)
IL-17A				0.53 (P < 0.01)	0.11 (P > 0.05)	0.27 (P < 0.01)	0.12 (P > 0.05)	0.71 (P < 0.01)	-0.52 (P < 0.01)
TNF-α					0.09 (P > 0.05)	0.16 (P > 0.05)	-0.03 (P > 0.05)	0.44 (P < 0.01)	-0.32 (P < 0.01)
IL-8						0.04 (P > 0.05)	0.02 (P > 0.05)	0.08 (P > 0.05)	-0.15 (P > 0.05)
IL-1β							0.39 (P < 0.01)	0.51 (P < 0.01)	-0.08 (P > 0.05)
CXCL-1								0.35 (P < 0.01)	-0.52 (P < 0.01)
Th17									-0.23 (P < 0.01)

CTSI: Balthazar Computed Tomography Severity Index; TNF-α: Tumor necrosis factor-alpha; IL: Interleukin.

Rhubarb administration reduced cytokine, chemokine, and Th17 lymphocyte production more effectively than control treatment during AP

Uncontrolled inflammation is a major driver of AP pathogenesis. Given the observed increases in TNF-α, IL-1β, IL-6, IL-8, IL-10, IL-17A, CXCL1, and the Th17/CD4⁺ ratio in patients with AP, 284 patients were randomly assigned to the rhubarb (n = 144) or saline (control; n = 140) groups to evaluate the therapeutic effect of rhubarb in AP. After seven days of treatment, the rhubarb group demonstrated greater reductions in serum proinflammatory cytokines compared with the control group, including TNF-α, IL-1β, IL-6, IL-8, IL-17A, and CXCL1 (Figure 3). Conversely, serum IL-10 levels were significantly higher in the rhubarb group than in the control group (Figure 3). Furthermore, rhubarb treatment effectively inhibited Th17 cell differentiation and reduced the Th17/CD4⁺ ratio in peripheral blood compared with the control group (Figure 3).

Figure 3 Rhubarb administration ablated the production of cytokines, chemokine and Th17 lymphocyte subsets more effective than the control group during acute pancreatitis. ^aP < 0.05; ^bP < 0.01; ^cP < 0.001. TNF-α: Tumor necrosis factor-alpha; IL: Interleukin.

IAP decreased more significantly in the rhubarb group than in control group

Given that IAP is an important indicator of AP severity, continuous IAP monitoring was performed in both groups. After five days of continuous treatment, IAP decreased more significantly in the rhubarb group than in the control group (Figure 4).

Figure 4 Intra-abdominal pressure in the rhubarb group decreased more significantly than in the control group. ^aP < 0.05. IAP: Intra-abdominal pressure.

Clinical endpoints

The primary and secondary endpoints are presented in Table 3. The primary endpoint was observed in 2 of the 144 patients in the rhubarb group and in 4 of the 140 patients in the control group. The 28-day mortality rate did not differ significantly between both groups (1.39% vs 2.86%, P = 0.39). The days of ICU stay was shorter in the rhubarb group (13 days) than in the control group (18 days), with insignificant difference (P = 0.47). However, the incidences of deep venous thrombosis (4.68% vs 15%, P = 0.004) and upper gastrointestinal hemorrhage (8.33% vs 16.43%, P = 0.03) were significantly lower in the rhubarb group than in the control group. The two groups showed comparable incidences of other complications, including gastrointestinal functional recovery time, intraperitoneal hemorrhage, and enteral nutrition recovery time.

Table 3 Clinical end points, n (%).

Characteristics	Rhubarb group (n = 144)	Controls group (n = 140)
Primary end point
Death failure	2 (1.39)	4 (2.86)
Secondary end points
Gastrointestinal function restoration to tolerate enteral nutrition time (day)	5 (4-9)	8 (5-14)
Intraperitoneal hemorrhage	3 (2.08)	5 (3.57)
Upper gastrointestinal hemorrhage	12 (8.33)	23 (16.43)a
Deep venous thrombosis	7 (4.86)	21 (15.00)b
ICU stay (day)	13 (7-16)	18 (6-21)

^aP < 0.05.

^bP < 0.01.

ICU: Intensive care unit.

DISCUSSION

AP is an acute inflammatory disease caused by pancreatic enzyme-mediated digestion of pancreatic tissue. Its clinical pathophysiology is complicated and associated with high mortality. Previous studies have demonstrated that pancreatic ischemia-reperfusion injury, inflammatory mediators, and intracellular inflammatory signaling pathways play an important role in AP development. The disease can trigger a systemic inflammatory response, leading to multiple organ dysfunction, with the gastrointestinal tract often being the first organ affected[18]. Both animal experiments and clinical studies have shown that the intestinal flora disorder in AP is characterized by an increased abundance of pathogenic bacteria, such as Escherichia coli, accompanied by the inhibition and reduction of beneficial bacteria, including Lactobacillus and Bifidobacterium. The release of bacterial toxins into the systemic circulation is an important initiating factor for systemic inflammatory responses in AP[19]. Among the inflammatory mediators, TNF-α, IL-1β, and IL-6 are the key drivers of inflammatory cascade reactions, and their mutual induction and synergistic effects can amplify systemic inflammation[20]. Consistent with these findings, our results showed that serum levels of TNF-α, IL-1β, IL-6, IL-8, and IL-17A were significantly higher in patients with AP than in healthy adults, indicating that AP occurrence is related to uncontrolled inflammation. Because AP itself represents an inflammatory process, the overexpression of inflammatory cytokines aggravates intestinal mucosal damage, promotes translocation of intestinal bacteria, and amplifies inflammatory cascades, ultimately resulting in pancreatic damage[21]. Therefore, clinical management of AP should prioritize controlling systemic inflammation and improving gastrointestinal function. Rhubarb has been reported to inhibit pancreatic enzyme activity, inhibit neutrophil infiltration and excessive macrophage activation, reduce inflammatory cytokine levels, and exert antibacterial and anti-inflammatory effects[22]. According to our results, treatment with rhubarb was associated with lower levels of proinflammatory cytokines, including TNF-α, IL-1β, IL-6, IL-8, and IL-17A, than in the control group, whereas the anti-inflammatory cytokine IL-10 was notably increased. These findings indicate that rhubarb enema can effectively improve the systemic inflammatory responses in patients with AP. In addition, bisanthraquinone glycosides, the main active components of rhubarb, stimulate intestinal peristalsis, promote exhaustion and defecation, and improve gastrointestinal function, which may explain the observed significant decrease in IAP following rhubarb enema treatment[23-25]. Although no statistically significant differences in intestinal functional recovery was observed between both groups, intestinal recovery time was shorter in the rhubarb group than in the control group, which may be related to the relatively small sample size.

Lymphocytes are important immune cells that mediate fluid and cellular immunity, which is critical in maintaining inflammatory balance. Evidence has shown that AP is not only a simple result of “trypsin autodigestion”, but is closely related to immune dysregulation[26]. CD4⁺ T lymphocytes are an important immune cell population capable of secreting both pro- and anti-inflammatory cytokines, regulating immune balance, and participating in immune cascades and inflammatory responses[27]. Previous studies have shown that monitoring Th17 cell activity can serve as an auxiliary indicator for evaluating AP severity[28]. During AP progression, the overexpression of proinflammatory cytokines enhances Th17 cell differentiation, resulting in Th17 immune hyperactivity and further aggravation of inflammatory responses[29]. Studies have confirmed that the cytokine IL-17A, mainly secreted by Th17 cells, is the main proinflammatory factor whose upregulation can amplify immune cascades and rapidly aggravate inflammatory responses[30]. IL-6, a key cytokine regulating T lymphocyte differentiation, is closely associated with Th17 cell differentiation. The overexpression of IL-6 can interact with transforming growth factor-beta to activate the T-cell expression transcription factor RORγT, thereby inducing Th17 cell maturation[31]. Our results demonstrated that Th17 lymphocyte subsets and cytokines IL-6 and IL-17A were significantly increased during the early stage of AP and were positively correlated with AP severity. Following rhubarb enema treatment, levels of Th17 cell subsets, IL-6, IL-17A, and other inflammatory factors were markedly reduced compared with the control group. These findings indicate that rhubarb can improve the inflammatory response in patients with AP by regulating Th17 cell differentiation and inflammatory cytokines. However, IL-1β was not significantly correlated with CTSI scores in this study. IL-1β primarily serves as the initial mediator that triggers the release of additional inflammatory cytokines from pancreatic or other tissues, subsequently inducing IL-6 and IL-8 production[32,33]. These factors also contribute to the disruption of the intestinal mucosal barrier and bacterial translocation, generating endotoxins that accelerate severe AP progression. The extent and severity of pancreatic necrosis during the early stages of severe AP, driven by the activation of multiple inflammatory cytokines, directly determine the disease’s severity[34]. These observations suggest that certain inflammatory pathways in AP exhibit a time lag in their effects.

Deep venous thrombosis is a serious complication of AP[35]. From the perspective of pathogenesis, AP causes severe systemic inflammatory reactions, increases the levels of inflammatory mediators, activates blood coagulation, inhibits fibrinolysis, and activates platelets, which are important factors involved in the formation of deep venous thrombosis[36]. Inflammatory cytokines, types of peptides that are secreted by immune cells, are essential in information exchange and coordination between tissues and cells. Besides inflammatory cytokines causing damage to its own tissue cells, it also promotes hypercoagulation, consumes coagulation factors, increases the production of fibrin degradation products, and induces microcirculation disorders. Furthermore, inflammatory cytokines can directly damage vascular endothelial cells, leading to coagulation-anticoagulation dysfunction and promotion of deep vein thrombosis[37]. Previous studies have shown that the overexpression of IL-6 due to uncontrolled inflammatory response correlates positively with the formation of deep vein thrombosis[38], while excessive consumption of the anti-inflammatory factor IL-10 correlates negatively with it[39]. This could be related to excessively activated coagulation and inhibition of fibrinolytic activity. Furthermore, our results show that following rhubarb enema treatment, IL-6 and other proinflammatory factors are downregulated, while IL-10 is less downregulated than in the control group, thereby indicating that the incidence of deep vein thrombosis was also smaller than that of the control group. Additionally, rhein, the active component in rhubarb, has been shown to improve high-fat diet-induced aortic endothelium-dependent relaxation dysfunction, reduce vascular stiffness, enhance vascular elasticity, and lower aortic inflammation levels[40-43]. Its therapeutic effects on cardiovascular disease have been well-established.

This study has several limitations. First, although there was no significant statistical significance in the improvement of patient survival and ICU stay in the hospital, the survival rate and ICU stay in the rhubarb treatment group showed a downward trend compared with the control group. This may be because of the relatively small cohort of patients with AP in this study, which may affect result generalizability and lead to bias. Second, due to potential sample differences from previous studies during sample size calculation, the actual number of critically ill patients was lower than anticipated. Post hoc tests were therefore employed for statistical comparisons. Future studies should refine population categorization for more accurate sample size estimation. Third, hypertriglyceridemia, a major risk factor for AP, accounted for more than 80% of the study sample. This study did not stratify AP etiology, constituting a limitation that may also affect result generalizability. Therefore, future studies should further stratify AP etiology as a confounder for analysis, as well as population stratification, dosage optimization, and long-term prognostic indicators.

CONCLUSION

In summary, rhubarb enema treatment effectively inhibits Th17 cell differentiation, reduces the release of inflammatory cytokines, improves the systemic inflammatory responses in patients with AP, and reduces the incidence of deep vein thrombosis. The clinical value of rhubarb enema as a treatment option for AP remains to be established in a clinical trial with a larger cohort regarding clinical state, pathogen type, and other possible factors.

ACKNOWLEDGEMENTS

All authors are very grateful to the clinical laboratory at the First Affiliated Hospital of Chongqing Medical University to provide laboratory facilities.