Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 9, No. 1, 1069-1077 2025 Publisher: Learning Gate DOI: 10.55214/25768484.v9i1.4309 © 2025 by the authors; licensee Learning Gate © 2025 by the authors; licensee Learning Gate History: Received: 27 November 2024; Revised: 10 January 2024; Accepted: 10 January 2025; Published: 17 January 2025 * Correspondence: fensurg@gmail.com Navigating the intussusception scoring system: A journey beyond boundaries Tarida Christio Ersanna Onlia Siahaan1, IGB Adria Hariastawa2, Fendy Matulatan3* 1Training Program in Pediatric Surgery, Departemen of Surgery, Dr. Soetomo General-Academic Hospital, Surabaya, Indonesia. 2,3Division of Pediatric Surgery, Departemen of Surgery, Dr. Soetomo General-Academic Hospital, Surabaya, Indonesia; fensurg@gmail.com (F.M.). Abstract: Bowel resection is usually performed in the operative management of pediatric intussusception patients when the strangulation process lasts for a long time, causing intestinal ischemia and necrosis. A combined scoring system of biological markers and clinical conditions of pediatric patients with intussusception can be a tool to help make decisions to perform appropriate and rapid intestinal resection to reduce patient morbidity and mortality. This was a retrospective cross- sectional study of pediatric intussusception patients undergoing laparotomy surgery at Dr. Soetomo Hospital in 2019 – 2024. The data were collected from electronic medical records, with 69 patients meeting the inclusion criteria, multivariate analysis was performed to obtain markers and ratios of inflammatory markers associated with the occurrence of intestinal necrosis in pediatric patients with intussusception. Of the total 69 subjects, 49 (58%) underwent bowel resection and the rest (29 [42%]) resolves without bowel resection, 49 (58%) was male and dominated by age group of < 12 months old (51 [73,9%]), the most common clinical symptoms were abdominal pain (68 of 69 [98,6%]). Using the Backward Stepwise method, 2 clinical factors were obtained in the form of significant vomiting and abdominal mass (p < 0.05) and a biological marker in the form of CAR cut off (p < 0.05). Conclusion: A scoring system could not be created in this study, but several variables could be used as components of a scoring system in the future study. Keywords: Bowel resection, Intussusception scoring system, Pediatric intussusception. 1. Introduction Intussusception is a condition where a proximal segment of the intestine telescopes into a distal segment, making it the most common cause of intestinal obstruction in infants. This pediatric emergency can lead to intestinal ischemia and necrosis, potentially necessitating bowel resection. Prompt diagnosis and treatment are crucial, as delays can be fatal. Management of intussusception typically begins with resuscitation. Non-surgical reduction using liquid or air enemas can be performed in patients without contraindications to this approach [1]. Surgical intervention is indicated when there is intestinal necrosis, perforation, or failure of non-operative reduction [2]. A scoring system can assist pediatric surgeons in making decisions during surgery, thereby reducing morbidity and mortality in pediatric intussusception patients. The classic triad of intussusception includes colicky abdominal pain, vomiting, and bloody stool. Laboratory tests showing elevated levels of C-reactive protein (CRP), neutrophil-lymphocyte ratio (NLR), CRP-lymphocyte ratio (CLR), and CRP-albumin ratio (CAR) can help indicate intestinal necrosis in intussusception cases. This study aims to obtain a combined scoring system as a sign for the need for bowel resection in cases of pediatric intussusception. https://orcid.org/0009-0006-4559-3796 https://orcid.org/0000-0001-5274-1079 https://orcid.org/0000-0001-5662-542X 1070 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 9, No. 1: 1069-1077, 2025 DOI: 10.55214/25768484.v9i1.4309 © 2025 by the authors; licensee Learning Gate 2. Methods This research is a retrospective cross-sectional study with an observational analytic approach. The population of this study was all pediatric patients (obtain from medical record data) diagnosed with intussusception between January 2019 and July 2024 at Dr. Soetomo General Hospital, Surabaya. The study was approved by the joint committee of ethics of the Dr. Soetomo General Hospital, Surabaya (1056/KEPK/VII/2024). The sample size is determined using the cross-sectional research formula, with total minimum of sample was 69 patients. The inclusion criteria using patients’ medical records diagnosed with intussusception and patients aged 0-18 years old. Exclusion criteria was incomplete medical record data, both subjective data and laboratory data that studied according to research variable in this study. Data was processed using the Statistical Package for the Social Sciences (SPSS) version 27.0. The collected data were tested using logistic regression to determine the predictive value (PR) of patient and laboratory factors evaluated against the incidence of bowel resection and non-bowel resection with the Chi-Square test. Receiver operating characteristics (ROC) analysis was used to determine the cut-off value of the independent variables studied. Data from medical records are guaranteed confidentiality by researchers with approval from the ethics committee. 3. Result 3.1. Demographic Data of Research Subjects The total subjects in this research population were 87 patients, with 69 pediatric patients remaining who had intussusception cases between January 2019 and July 2024. These patients were treated by the Pediatric Surgery Division of the General Surgery Department at Dr. Soetomo Hospital in Surabaya, Indonesia, following the elimination process based on inclusion and exclusion criteria. From the population, 40 (58%) were male, and 29 (42%) were female. The oldest patient was 10 years old, while the youngest was 2 months old. We categorized the subjects into two age groups: <12 months, comprising 51 (73.9%) patients, and ≥12 months, comprising 18 (26.1%) patients. Additionally, the population was predominantly composed of subjects who underwent intestinal resection, totaling 40 (58%) patients Table 1. Table 1. Demographic data of research subjects. Variable Total [n (%)] Gender Boy 40 (58) Girl 29 (42) Age < 12 months 51 (73,9) ≥ 12 months 18 (26,1) Bowel resection Yes 40 (58) No 29 (42) In this population, it was found that out of 56 patients (81.2%), 38 of them underwent intestinal resection due to vomiting. Additionally, nearly the entire population—68 patients (98.6%)—experienced colicky abdominal pain, with 39 of them undergoing intestinal resection. Furthermore, 64 patients (92.8%) reported passing mucus and blood in their stools, and 38 (55.1%) of them underwent resection. The onset of symptoms to the time of intestinal resection ranged from 2 to 7 days (Table 2). In the physical examination, it was found that 38 patients (55.1%) had abdominal masses, and pseudoportio was detected in 24.6% (17 patients) of the population. Regarding laboratory tests, patients who underwent intestinal resection showed varying hemoglobin (Hb) levels, with a minimum of 5.5 g/dL and a maximum of 15.4 g/dL, with an average Hb level of 10.16 g/dL. The lowest hematocrit (HCT) level in patients undergoing intestinal resection was 16.6%, while the highest was 48.0%, with an average of 30.50%. The highest platelet count in patients undergoing intestinal resection was 898,000/µL, and the lowest was 127,000/µL, with an average of 464,320/µL. The lowest white blood cell (WBC) count in patients undergoing intestinal resection was 2,860/µL, while the highest was 1071 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 9, No. 1: 1069-1077, 2025 DOI: 10.55214/25768484.v9i1.4309 © 2025 by the authors; licensee Learning Gate 21,520/µL, with an average of 11,940/µL. Lymphocyte levels in patients undergoing intestinal resection ranged from a minimum of 8.40% to a maximum of 57.30%, with an average of 30.02%. Neutrophil levels ranged from a minimum of 19.10% to a maximum of 83.00%, with an average of 55.89% (Table 2). Table 2. Characteristic of research subjects. Variable Total [n(%)] Bowel resection [n(%)] History taking Vomit Present 56 (81.2) 38 (55.1) Absent 13 (18.8) 2 (2.9) Abdominal colic pain Present 68 (98.6) 39 (56.5) Absent 1 (1.4) 1 (1.4) Red currant jelly stool Present 64 (92.8) 38 (55.1) Absent 5 (7.2) 2 (2.9) Physical examination Abdominal mass Present 38 (55.1) 31 (44.9) Absent 31 (44.9) 9 (13) Pseudoportio Present 17 (24.6) 9 (13) Absent 52 (75.4) 31 (44.9) Laboratories examination Cut off CAR ≤ 0.96 32 (46.4) 9 (13) > 0.96 37 (53.6) 31 (44.9) Cut off LCR ≥ 7.75 32 (46.4) 11 (15.9) < 7.75 37 (53.6) 29 (42) In Table 3, the researchers also included ratios from several laboratory test results, such as NLR, CAR, and LCR. Among the subjects who underwent intestinal resection, the lowest NLR, CAR, and LCR values were 0.46, 0.11, and 0.65, respectively, while the highest values were 9.48, 7.02, and 89.60, respectively. The average values for these three variables were 2.36, 3.09, and 10.64, respectively. Additionally, 32 (46.4%) patients had a CAR cutoff ≤ 0.96, while 37 (53.6%) had a CAR cutoff > 0.96. Regarding LCR, 32 (46.4%) patients had an LCR cutoff ≥ 7.75, and 37 (53.6%) had an LCR cutoff < 7.75 (Table 2) Table 3. Characteristic of research subjects. Variable Bowel resection Lowest value Highest value Middle value Average Onset (day) Present 2 7 3.5 4.08 Absent 1 21 3 2.52 Hb Present 5.5 15.4 10 10.16 Absent 7.6 11.7 9.9 9.92 HCT Present 16.6 48.0 30.40 30.50 Absent 22.4 35.2 29.90 29.98 Platelet Present 127 898 433 464.32 Absent 177 773 479 468.20 WBC Present 2.86 21.52 11.7 11.94 Absent 3.38 36.28 10.96 13.17 Lymphocyte Present 8.40 57.30 29.75 30.02 Absent 3.92 64.20 32.50 32.67 Neutrophil Present 19.10 83.00 57.55 55.89 Absent 21.80 79.30 55.20 54.67 NLR Present 0.46 9.48 1.90 2.36 Absent 0.34 12.09 1.83 2.44 CAR Present 0.11 7.02 3.45 3.09 Absent 0.05 2.29 0.58 0.70 LCR Present 0.65 88.60 3.00 10.64 1072 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 9, No. 1: 1069-1077, 2025 DOI: 10.55214/25768484.v9i1.4309 © 2025 by the authors; licensee Learning Gate Absent 2.12 176.47 15.19 27.53 3.2 The Relationship of the Variables Studied with the Act of Intestinal Resection In Table 4, the relationship between the variables studied and intestinal resection was examined. Among all the variables studied, only vomiting events (p = 0.003, p < 0.05), the presence of abdominal masses (p = 0.000, p < 0.05), and laboratory test results in the form of CAR and LCR cutoffs (p = 0.000, p < 0.005) showed significant associations with intestinal resection. In the scoring system testing, researchers employed a multivariate test using the Backward Stepwise method. After passing through three elimination stages, it was found that variables such as vomiting, abdominal mass, and the CAR (cutoff point) can be consistently used to determine whether intestinal resection is necessary in cases of pediatric intussusception (Table 5). Table 4. Relationship of the variables studied with the action of intestinal resection. Variable P value Gender 0.062 Age 0.809 Vomit 0.003 Abdominal mass 0.000 Abdominal colic pain 1.000 Onset 0.602 Pseudoportio 0.629 Red currant jelly stool 0.408 Hb 0.585 HCT 0.676 Platelet 0.916 WBC 0.415 Lymphocyte 0.387 Neutrophil 0.744 NLR 0.702 CAR Cut Off 0.000 LCR Cut Off 0.000 Table 5. Multi variate analysis. Variable P value Step 1 Geder 0.800 Vomit 0.046 Abdominal mass 0.053 CAR cut off 0.041 LCR cut off 0.987 Constanta 0.003 Step 2 Gender 0.798 Vomit 0.041 Abdominal mass 0.052 CAR cut off 0.008 Constanta 0.003 Step 3 Vomit 0.039 Abdominal mass 0.037 CAR cut off 0.008 Constanta 0.000 4. Discussion Intussusception is a condition where a segment of the proximal intestine folds into the distal part of the intestine, which is the most common cause of intestinal obstruction. According to the CMUI scoring 1073 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 9, No. 1: 1069-1077, 2025 DOI: 10.55214/25768484.v9i1.4309 © 2025 by the authors; licensee Learning Gate system, four groups of factors—demographics, clinical symptoms, clinical signs (physical examination), and radiological findings are used to determine the risk factors for non-operative reduction failure. Other researchers have modified the CMUI scoring system by adding biomarkers, eliminating the reduction method, and adjusting the patient’s weight threshold, resulting in higher sensitivity and specificity for the risk of non-operative reduction failure [3]. The operative procedure performed for intussusception is manual reduction laparotomy, where the decision for intestinal resection depends on the condition of the intestine, which may experience ischemia and progress to necrosis. Factors associated with intestinal necrosis include Albumin and CRP as significant infection markers [4]. 4.1. Bowel Resection in Pediatric Intussusception Patients at Dr. Soetomo General Hospital, Surabaya The group is dominated by male patients, which occurs because boys with good nutrition have a faster growth rate compared to girls of the same age. Well-nourished Children have a higher risk of developing intussusception compared to children with poor nutrition. This is related to the complex immune system that occurs in the intestines [5, 6]. This group is also dominated by patients under 12 months of age, which aligns with Al-Salem, et al., that the incidence of intussusception in children peaks between 4 and 9 months of age [7]. 4.2. Gender In this study, we found that there was no relationship between gender and bowel resection surgery. This is consistent with the research conducted by Ajao, et al. [8] and Ezomike, et al. [9] who stated that there was no relationship between gender and the performance of bowel resection in cases of intussusception [8, 9]. However, study by Yao et al., stated that female patients with intussusception are at higher risk of undergoing bowel resection, while Huang, et al. [10] found that male patients with intussusception have a higher risk of undergoing bowel resection compared to female patients [8, 10, 11]. 4.3. Age Nisar et al. stated that age is not related to bowel resection, which is in line with the study conducted by Yao et al., where no relationship was found between loss of bowel viability and age. Similar results were also shown in the study conducted by Ezomike, et al. [9] In our study, we found results consistent with these three studies, where there was no significant relationship between age and bowel resection in pediatric intussusception cases [12]. 4.4. Vomiting Ravitch and Young, as mentioned in Ein and Daneman, also revealed that vomiting is the most common initial symptom in intussusception cases. Both Toronto series found that vomiting is the second most common symptom after pain in intussusception cases [7, 13]. This aligns with our analytical findings that vomiting is significantly associated with intestinal resection. 4.5. Abdominal Mass A ‘sausage-shaped’ mass is often found due to the progression of this disease. More than 90% of patients present with vomiting and bloody stools, while 60% present with a palpable mass [14]. In this study, the emergence of an abdominal mass in children with intussusception was significantly associated with the likelihood of undergoing resection in intussusception cases. 4.6. Abdominal Colic Pain Wu et al. demonstrated that one of the reasons for deciding on surgical intervention is the presence of peritonitis or the emergence of severe pain caused by intestinal necrosis or ischemia [15]. Abdominal pain is closely associated with an increased risk of bowel resection and independently predicts the need 1074 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 9, No. 1: 1069-1077, 2025 DOI: 10.55214/25768484.v9i1.4309 © 2025 by the authors; licensee Learning Gate for surgical intervention. Typically, abdominal pain is characterized by intermittent cries and leg pulling toward the abdomen. However, abdominal pain remains a classic symptom of intussusception and occurs in a significant number of patients where non-operative management is sufficient. Interestingly, abdominal pain may be more pronounced in infants and could indicate a worse prognosis. Often, this pain is less noticeable in infants compared to older children, where abdominal pain is the primary presenting symptom [8]. This is in line with data regarding the most common complaint in this research, which is colicky abdominal pain. Despite statistically insignificant correlations, most patients still undergo bowel resection. This phenomenon may occur due to the wide range of causes of colicky pain. Additionally, it is challenging to obtain an accurate pain history from non-verbal children or parents who may not be aware that their child is in pain. Such conditions pose a significant challenge for healthcare providers [16]. 4.7. Onset Chalya et al., found that clinical delay of more than 24 hours since the onset of symptoms significantly correlates with the decision to perform bowel resection [17]. Some studies also showed that 84.6% of patients who arrived early (≤ 24 hours) successfully underwent intussusception reduction, compared to patients who arrived late (> 24 hours), where only 54.1% achieved reduction, and 45.9% required bowel resection [12, 18]. This contrasts with the data in this study, where there was no significant association between symptom onset and the decision to perform bowel resection. This lack of significance may be due to challenges in obtaining accurate pain history from parents or caregivers who may not fully understand when the patient actually began experiencing symptoms. 4.8. Pseudoportio Pseudoportio refers to a condition where the portion of the intestine affected by intussusception is exceptionally long, making it palpable during rectal examination. Although this occurrence is relatively rare (only 5% among cases), the discovery of pseudoportio indicates that intussusception has progressed to an advanced stage, implying a worsened prognosis. This progression results from obstruction within the digestive system, which, if left untreated, can lead to ischemia and eventual intestinal necrosis. However, in this study, no significant association was found between pseudoportio and the decision to perform bowel resection. Currently, there are no other studies discussing the between pseudoportio and prognosis or the need for surgical resection in pediatric intussusception patients. Further research is necessary to explore the connection between the emergence of pseudoportio and the decision for bowel resection [19]. 4.9. Red Currant Jelly Stool "Red currant jelly stool" is a sign of impending ischemia in cases of intussusception. This symptom is considered rare or not always present in intussusception cases. A study showed that patients with intussusception who present with red currant jelly stool have a higher risk of experiencing pneumatic reduction failure, which ultimately leads to the need for bowel resection [15, 20]. In this study, we found that bloody mucus stools did not have a significant correlation with bowel resection. This may be due to differing understandings between doctors and patients, leading to errors in data reporting during the anamnesis process. 4.10. Hemoglobin Anemia can occur in cases of intussusception due to prolonged ischemia, which causes the intestine to become necrotic. Nisar et al. showed that anemia can be considered a determining factor for bowel resection, with pediatric intussusception patients having hemoglobin levels < 10 mg/dL being 2.7 times more likely to undergo bowel resection. This contrasts with the findings of this study, where hemoglobin levels did not have a significant relationship with bowel resection. This discrepancy may be 1075 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 9, No. 1: 1069-1077, 2025 DOI: 10.55214/25768484.v9i1.4309 © 2025 by the authors; licensee Learning Gate due to the broad range of causes of anemia. Additionally, this study had fewer samples compared to Nisar et al.'s study, and we did not define the inclusion and exclusion criteria that could be factors for anemia, such as malnutrition, which can also cause anemia [21, 22]. 4.11. Hematocrit Hematocrit can also indicate anemia if HCT levels drop below 30%. Nisar et al., showed that pediatric intussusception patients with HCT levels < 30% had a 2.6 times higher risk of undergoing bowel resection. This contradicts the findings of this study, where HCT levels did not have a significant relationship with bowel resection, which is consistent with the results for hemoglobin levels [12]. 4.12. Platelet Budiananti et al. showed that platelet levels do not have a significant relationship with the occurrence of intestinal necrosis in pediatric intussusception cases. This is consistent with our study, where platelet levels also did not have a significant relationship with the decision to perform bowel resection in pediatric intussusception cases [4]. 4.13. White Blood Cell White blood cells are often used as biomarkers to detect infections. Thuijls et al., found that WBC levels did not have a significant relationship when compared between groups with mesenteric ischemia and non-mesenteric ischemia [23]. This is consistent with the findings of this study, where WBC levels did not have a significant relationship with bowel resection in pediatric intussusception cases. This may be because WBC levels can increase due to infections in other areas and do not specifically indicate infection in a particular region or organ. 4.14. Lymphocyte Lymphocyte levels decrease as the inflammatory process increases, due to the excessive secretion of cortisol. In this study, the average lymphocyte count in the group that did not undergo bowel resection was indeed lower compared to the group that underwent resection, but statistically, there was no significant relationship between lymphocyte levels and bowel resection in pediatric intussusception patients. This clearly contradicts the existing theory, which may be due to the small sample size in this study [4]. 4.15. Neutrophil Neutrophils, also known as polymorphonuclear leukocytes (PMNs), under homeostatic conditions, enter the circulation, migrate to tissues, and are eventually engulfed by macrophages. Neutrophils are important effector cells in the immune system [24]. A previous study at Dr. Soetomo General Hospital stated that there is no significant relationship between neutrophils and the occurrence of intestinal necrosis [4]. A similar finding was also observed in this study, where neutrophils did not have a significant relationship with the need for bowel resection. 4.16. Neutrophil-Lymphocyte Ratio The neutrophil-to-lymphocyte ratio plays a role in indicating an inflammatory response resulting from intestinal ischemia. NLR typically increases in bacterial infections, where neutrophils are released to migrate to the site of infection. After 12-20 hours, the bone marrow will increase the production of immature neutrophils into the bloodstream, resulting in a left shift in the white blood cell count [25]. Lymphocyte levels decrease due to excess cortisol during inflammatory reactions, which subsequently affects physiological stress and lowers lymphocyte counts. Lymphocyte suppression also occurs due to the release of inflammatory factors such as TNF-α and IL-6 [19, 26]. In relation to this study, the neutrophil-to-lymphocyte ratio has an insignificant effect on the decision to perform bowel 1076 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 9, No. 1: 1069-1077, 2025 DOI: 10.55214/25768484.v9i1.4309 © 2025 by the authors; licensee Learning Gate resection, which aligns with the previous analyses of the relationship between lymphocytes and neutrophils. 4.17. C-Reactive Protein Ratio An increased ratio of CRP to albumin will influence the decision to perform bowel resection. According to theory, if intestinal necrosis occurs, CRP levels will rise, which can lead to hypoalbuminemia due to systemic inflammation. The researchers chose to use a cut-off for the CAR to simplify the scoring system. The results of this study differ from those of Chen, et al. [27] where the CRP-albumin ratio was found to be insignificant [27]. 4.18. Lymphocyte-C-Reactive Protein Ratio The lymphocyte-C-reactive protein ratio was found to be significantly lower in patients who underwent bowel resection compared to those who did not. This ratio is significant as an indicator for bowel resection in cases of intussusception. Chen et al. concluded that the LCR serves as a high-value indicative marker that is easy to apply using routine examinations without additional costs [27]. Although previous studies indicated that a low LCR was significant for bowel resection, the researchers did not choose LCR as a variable in this study because it is still considered a covariate of CAR. The components of CAR, which include CRP and albumin, are theoretically believed to provide higher accuracy in determining the need for bowel resection [4, 27]. 4.19. Combined Scoring System for Bowel Resection in Pediatric Intussusception This study identified three factors that can be included in a scoring system: the presence of vomiting, abdominal mass findings, and the cut-off CAR from supporting examinations. The results were far from the researchers' expectations, as only a few of the factors studied could contribute to the scoring system. This research has several limitations: first, the small sample size; second, the absence of CRP data, particularly at the beginning of the study; third, a high level of subjectivity during the anamnesis process, leading to hopes for a standardized anamnesis to reduce examiner bias; and finally, the transition from traditional medical records to digital records during the study, which resulted in some incomplete data in the medical records. 5. Conclusion While a scoring system could not be developed in this study, the findings can pave the way for creating a scoring system to guide bowel resection decisions in pediatric intussusception cases. This could be achieved by incorporating factors from anamnesis, physical examinations, and supporting diagnostic tests. Transparency: The authors confirm that the manuscript is an honest, accurate, and transparent account of the study; that no vital features of the study have been omitted; and that any discrepancies from the study as planned have been explained. This study followed all ethical practices during writing. Copyright: © 2025 by the authors. This open-access article is distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/). References [1] T. Charles, L. Penninga, J. C. Reurings, and M. C. J. Berry, "Intussusception in children: A clinical review," Acta Chirurgica Belgica, vol. 115, no. 5, pp. 327-333, 2015. https://creativecommons.org/licenses/by/4.0/ 1077 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 9, No. 1: 1069-1077, 2025 DOI: 10.55214/25768484.v9i1.4309 © 2025 by the authors; licensee Learning Gate [2] O. Feldman et al., "Success rate of pneumatic reduction of intussusception with and without sedation," Paediatric Anaesthesia, vol. 27, no. 2, pp. 190–195, 2017. https://doi.org/10.1111/pan.13045 [3] K. Boonsanit, S. Kritsaneepaiboon, P. Chiengkriwate, and S. Sangkhatat, "Validation and modification of the “Chiang Mai University Intussusception scoring system” used to predict failure of non-surgical treatment in infantile intussusception," World Journal of Pediatric Surgery, vol. 2, no. 3, pp. 1–7, 2019. https://doi.org/10.1136/wjps-2019- 000060 [4] A. Budiananti, I. Hariastawa, and F. Dan Matulatan, "Correlation between pathology indicators and intestinal necrosis in pediatric intussusception," Chirurgia, vol. 37, no. 3, pp. 183-7, 2023. https://doi.org/10.23736/s0394- 9508.23.05647-4 [5] E. Verduci and J. Koglmeier, "Immunomodulation in children: The role of the diet," Journal of Pediatric Gastroenterology and Nutrition, vol. 73, no. 3, pp. 293 - 298, 2021. https://doi.org/10.1097/mpg.0000000000003152 [6] J. Salazar and N. Vo, "Intussusception in children', UpToDate," Retrieved: https://www.uptodate.com/contents/intussusception-in-children. [Accessed 2024. [7] A. H. Al-Salem, Intussusception. In: Atlas of pediatric surgery. Cham: Springer, 2020. [8] A. Ajao, T. Lawal, O. Ogundoyin, and D. Olulana, "Clinical predictors and outcome of bowel resection in paediatric intussusception," African Health Sciences, vol. 20, no. 3, pp. 1463–1470, 2020. [9] U. O. Ezomike et al., "Trends in childhood intussusception in a Nigerian tertiary hospital," African Health Sciences, vol. 24, no. 1, pp. 123-130, 2024. [10] Y. Huang, H. Lee, and C. Chen, "Laparoscopic-assisted versus open surgery for intussusception in children: A systematic review and meta-analysis," Pediatric Surgery International, vol. 30, no. 8, pp. 781-787, 2014. [11] X. M. Yao et al., "Risk factors for pediatric intussusception complicated by loss of intestine viability in China from June 2009 to May 2014: A retrospective study," Pediatric Surgery International, vol. 31, pp. 163-166, 2015. https://doi.org/10.1016/j.jpedsurg.2018.03.023 [12] M. U. Nisar, S. Sikander, and N. Khan, Determinants of bowel resection in childhood intussusception. Islamabad-Pakistan: Pakistan Institute of Medical Sciences, JAMC, 2020. [13] d. D. Ein, E. SH., and A. Daneman, Intussusception. In: Grosfeld JL, O’Neill JA, Coran AG, Fonkalsrud EW, Pediatric surgery, 6th ed. Philadelphia: Mosby Elsevier, 2006. [14] S. Cox et al., "Clinical presentation and management of childhood intussusception in South Africa," Pediatric Surgery International, vol. 37, pp. 1361–1370, 2021. [15] T. H. Wu, G. S. Huang, C. T. Wu, J. Y. Lai, C. C. Chen, and M. H. Hu, "Clinical characteristics of pediatric intussusception and predictors of bowel resection in affected patients," Frontiers in Surgery, vol. 9, pp. 1–7, 2022. https://doi.org/10.21203/rs.3.rs-1042649/v1 [16] J. Banks, A. Rouster, and J. Chee, "Infantile colic', Statpearls," Retrieved: https://www.ncbi.nlm.nih.gov/books/NBK518962/. [Accessed 2023. [17] P. Chalya, N. Kayange, and A. Chandika, "Childhood intussusceptions at a tertiary care hospital in northwestern Tanzania: A diagnostic and therapeutic challenge in resource-limited setting," Italian Journal of Pediatrics, vol. 40, no. 1, pp. 1–8, 2014. https://doi.org/10.1186/1824-7288-40-28 [18] A. Gadisa, A. Tadesse, and B. Hailemariam, "Patterns and seasonal variation of intussusception in children: A retrospective analysis of cases operated in a tertiary hospital in Ethiopia," Ethiopian Medical Journal, vol. 54, no. 1, pp. 9-15, 2016. [19] A. D. Coran, Pediatric Surgery. 7th edn. Edited by Adzick N. Scott; Krummer Thomas M.; Laberge Jean-Martin; Shamberger Robert C.; Caldamone Anthony. Philadelphia: Elsevier Saunders., 2012. [20] M. A. Attoun et al., "The management of intussusception: a systematic review," Cureus, vol. 15, no. 11, pp. 1- 9, 2023. [21] T. Wright and M. Fallat, Intussusception'. In Holcomb GW., Murphy JP., and St Peter SD. Holcomb and Ashcraft’s Pediatric Surgery, 7th ed. Elsevier, 2020. [22] K. Nagakari et al., "Intestinal intussusception and progressive anemia due to pyogenic granuloma of the ileum: A case report," Surgical Case Reports, vol. 7, pp. 1-4., 2021. https://doi.org/10.1186/s40792-021-01170-2 [23] G. Thuijls et al., "Early diagnosis of intestinal ischemia using urinary and plasma fatty acid binding proteins," Annals of Surgery, vol. 253, no. 2, pp. 303-308, 2011. [24] C. Rosales, "Neutrophil: A cell with many roles in inflammation or several cell types?," Frontiers in physiology, vol. 9, p. 324475, 2018. https://doi.org/10.3389/fphys.2018.00113 [25] N. Ishimine et al., "Combination of white blood cell count and left shift level real-timely reflects a course of bacterial infection," Journal of Clinical Laboratory Analysis, vol. 27, no. 5, pp. 407-411, 2013. https://doi.org/10.1002/jcla.21619 [26] R. Guo, H. Wang, and N. Cui, "Autophagy regulation on pyroptosis: Mechanism and medical implication in sepsis," Mediators of inflammation, vol. 2021, no. 1, p. 9925059, 2021. https://doi.org/10.1155/2021/9925059 [27] B. Chen, J. Cao, C. Yan, C. Zheng, J. Chen, and C. Guo, "A promising new predictive factor for detecting bowel resection in childhood intussusception: The lymphocyte-C-reactive protein ratio," BMC Pediatrics, vol. 21, pp. 1-6, 2021. https://doi.org/10.1186/s12887-021-03068-2 https://doi.org/10.1111/pan.13045 https://doi.org/10.1136/wjps-2019-000060 https://doi.org/10.1136/wjps-2019-000060 https://doi.org/10.23736/s0394-9508.23.05647-4 https://doi.org/10.23736/s0394-9508.23.05647-4 https://doi.org/10.1097/mpg.0000000000003152 https://www.uptodate.com/contents/intussusception-in-children https://doi.org/10.1016/j.jpedsurg.2018.03.023 https://doi.org/10.21203/rs.3.rs-1042649/v1 https://www.ncbi.nlm.nih.gov/books/NBK518962/ https://doi.org/10.1186/1824-7288-40-28 https://doi.org/10.1186/s40792-021-01170-2 https://doi.org/10.3389/fphys.2018.00113 https://doi.org/10.1002/jcla.21619 https://doi.org/10.1155/2021/9925059 https://doi.org/10.1186/s12887-021-03068-2