Meckel’s diverticulum (MD) is the most common congenital anomaly detected in the gastrointestinal system, with a prevalence of 1–3% in the general population.^[1] It occurs due to the incomplete obliteration of the vitelline (omphalomesenteric) duct during the fifth to seventh week of gestation. As in true diverticulum, Meckel’s diverticulum contains all three layers of the intestinal wall, and it is typically located on the antimesenteric border of the ileum, approximately 40–100 cm proximal to the ileocecal valve.^[2,3] Although its estimated prevalence is around 2%, the majority of cases remain asymptomatic throughout life, with only 4–6% developing complications that necessitate surgical intervention.^[3,4]

In the pediatric population, Meckel’s diverticulum can present with a wide spectrum of clinical manifestations, often mimicking other acute abdominal conditions. The most common symptomatic presentations include painless lower gastrointestinal bleeding, intestinal obstruction, intussusception, diverticulitis, and, less frequently, perforation. These complications are often attributed to the presence of ectopic mucosa, most commonly gastric or pancreatic, which can lead to ulceration, inflammation, or serve as a lead point for volvulus or intussusception.^[2,3] The diversity in presentation, along with the nonspecific symptoms, causes the significant diagnostic challenge, particularly in resource-limited settings. Preoperative diagnosis of Meckel’s diverticulum remains elusive in many cases. While technetium-99m pertechnetate scintigraphy (Meckel’s scan) is the investigation of choice, specifically for detecting ectopic gastric mucosa, its sensitivity is limited in the absence of bleeding or in cases with atypical presentations.^[5] Ultrasonography and computed tomography (CT) may aid in identifying complications such as obstruction or perforation but are not definitive for diagnosing Meckel’s diverticulum itself.^[5,6] Consequently, many cases are diagnosed intraoperatively, either during exploration for acute abdomen or incidentally during unrelated procedures.

Surgical resection remains the definitive treatment for Meckel’s diverticulum. The choice between simple diverticulectomy and segmental ileal resection depends on intraoperative findings, including the presence of inflammation, perforation, ischemia, or suspicion of ectopic muco- sa.^[6] Laparoscopy and the minimal invasive approach have gained acceptance increasingly due to their diagnostic ability, reduced morbidity, and shorter recovery.^[7,8]

Despite its clinical significance, there remains a paucity of prospective data from developing countries on the presentation, management, and outcomes of Meckel’s diverticulum in the pediatric population. This study was undertaken to bridge this gap by analyzing the clinical spectrum, diagnostic modalities, operative findings, histopathological features, and postoperative outcomes of pediatric Meckel’s diverticulum cases managed at a tertiary care center.

This study aims to enhance understanding of Meckel’s diverticulum’s clinical behavior, support timely diagnosis, and guide optimal surgical management strategies in pediatric patients presenting with acute abdomen or incidental Meckel’s diverticulum.

The present prospective cross-sectional observational study was carried out at a tertiary care hospital from November 2021 to October 2025. All children below 18 years who were diagnosed with Meckel’s diverticulum and underwent surgical treatment or children who found Meckel’s diverticulum incidentally during another surgery, irrespective of sex, were included in the study.

From all children, data for sex, age of presentation, clinical features, diagnostic method, and surgical treatment were analyzed. Stabilization and vigorous management were undertaken before taking up children for operative management. Detailed history, complete blood count, serum creatinine level, blood urea nitrogen, and blood glucose levels were performed. Abdominal ultrasonography and computed tomography were performed in all cases. Intravenous fluids were chosen according to patient status, and all patients were empirically started on third-generation cephalosporins and metronidazole, and antibiotics were escalated based on culture and sensitivity reports. Patients were taken up for surgical management after stabilization. After excision of Meckel’s diverticulum, the specimen was sent for histopathological examination. In all children, postoperative complications, hospital stay, outcomes, and histopathological findings were recorded and were analyzed.

A total of 28 cases were diagnosed with Meckel’s diverticulum and treated surgically in the tertiary care hospital during the specified study period. We noticed male predominance, with males accounting for 71.43% of all cases and 28.57% of cases being female (Table 1), with a male-to-female ratio of 2.5:1. According to the clinical presentations in all cases of diverticulitis, intestinal obstruction, intussusception, and perforation, the sex distribution was more in men (Table 1). At the time of diagnosis, the age ranged from 6 months to 17 years; the most affected age group was aged 1 to 5 years, accounting for the highest proportion of cases (42.86%), followed by those aged >5 to 10 years (32.14%). Infants (<1 year) represented 14.29% of cases, with a notable presence of intussusception and perforation (Table 2).

Intestinal obstruction (28.57%) was the most common pathology overall, with a 3:1 male-to-female ratio followed by intussusception (21.43%) and perforation (17.86%). Intestinal obstruction and perforation are commonly seen in 1 to 5 years; diverticulitis was rare overall but evenly distributed between >5–10 years and >10 years. Incidentally found cases were mostly in >5–10 years (3 cases), suggesting increased incidental detection with age.

In our study, in patients presenting with intestinal obstruction, the most common symptoms were vomiting (100%) and abdominal distention (100%), followed by pain (87.5%); in cases with presentation of diverticulitis, the most common symptoms were pain (100%) and fever (100%), followed by vomiting (50%); in cases presented with perforation, the most common symptoms were pain (100%), followed by vomiting (80%) and fever (60%). In cases presented with intussusception, the common symptoms were pain (100%), vomiting (100%), and lump (100%), followed by abdominal distention (83.3%). Cases of intussusception also have melena in 66.7% of cases (Table 3). In our study, 5 cases were incidentally detected during another surgery. Two cases were detected during surgery for acute appendicitis, two were detected during surgery for malrotation of the gut, and the other was detected while performing laparotomy for congenital megacolon.

Abdominal ultrasonography and computed tomography (CT) scans were performed in all cases. Meckel’s scan was performed in only 4 cases with diverticulitis, and all 4 (100%) showed a positive tracer.

During surgery, all cases of intestinal obstruction had obstruction due to Meckel’s band attached to the umbilicus; diverticulitis cases had inflamed Meckel’s with a fecalith in one case; perforation was most common near the tip in 3 (60%) cases; and in all cases of intussusception, Meckel’s diverticulum was the leading point.

Meckel’s diverticulum was located 25 cm to 80 cm proximal to the ileocecal valve, at the antimesenteric border of the ileum, with a mean of 59.6 cm from the ileocecal valve. The size of Meckel’s diverticulum ranged from 1.5 cm to 15 cm with a mean of 4.5 cm, and a diameter of 0.5 to 4 cm with a mean of 1.8 cm.

All patients underwent laparoscopic-assisted segmental ileal resection with anastomosis, as most diverticula were associated with inflammation or ischemic changes and a high likelihood of ectopic tissue.

There were only 2 cases of wound infections postoperatively, which were managed with dressing. The mean hospital stay was 5.6 days.

On histopathological study, ectopic tissue was noticed in 19 (67.86%) cases. Gastric mucosa was noticed in 16 cases (57.14%), pancreatic tissue was in 1 (4.2%), and both gastric and pancreatic tissue were seen in 2 (7.14%) cases. According to the presentation, ectopic tissue was most observed in 100% (5) of cases with perforation followed by intussusception (83.3%) and diverticulitis (75%) (Table 4).

Meckel’s diverticulum (MD), the most prevalent congenital anomaly, although often asymptomatic, can present with a wide range of complications in pediatric patients, including intestinal obstruction, intussusception, diverticulitis, and perforation, as observed in our cohort.^[6] The rule of 2 is commonly used to describe Meckel’s diverticulum and refers to a male-to-female ratio of 2:1, a prevalence of 2%, an incidence of 2%, a symptomatic rate of 2%, a diverticular length of 2 inches, the occurrence of symptoms before 2 years of age, the location of diverticulum 2 feet from the ileocecal valve, and 2 common types of ectopic tissues.^[6,7]

Male predominance (71.43%) in our study aligns with previous literature.^[1,2,9], where symptomatic Meckel’s diverticulum is more frequently reported in males.^[2,3] The most affected age group was 1–5 years, consistent with the peak incidence of symptomatic presentations in early child- hood.^[2,9,10]

The peak incidence in the 1–5 year age group aligns with prior findings by Soltero and Bill^[11], who noted that most symptomatic cases occur before the age of 10 years. The clinical presentation of Meckel’s diverticulum is nonspecific and diverse, which makes diagnosis difficult. However, children with complicated Meckel’s diverticulum can present as a surgical emergency with diverticulitis, intesti- nal obstruction, intussusception, and gastrointestinal bleeding.^[1,6,10] Intestinal obstruction emerged as the most common presentation (28.57%), followed by intussusception and perforation. This distribution mirrors findings from Park et al.^[12], who reported obstruction as the leading complication in children, often due to fibrous bands or volvulus around the Meckel’s diverticulum.

Intussusception (21.43%) was the second most common presentation, with Meckel’s diverticulum serving as a pathological lead point in all cases. This finding corroborates studies that identify Meckel’s diverticulum as a frequent lead point in non-idiopathic intussusception, particularly in children over 2 years of age.^[6,9] The presence of ectopic gastric mucosa in 67.86% of cases, particularly in perforation and intussusception, reinforces the pathogenic role of acid secretion in mucosal injury and ulceration.^[6,9]

Diagnostic imaging remains challenging despite the availability of the modern imaging modalities. While ultrasonography was widely used, it remains a useful first-line tool, particularly in cases of obstruction or intussusception. CT and technetium-99m pertechnetate radionuclide scans are largely used in the diagnosis of Meckel’s diverticu- lum.^[5-7]CT imaging was selectively employed and aided in identifying complications such as perforation or inflammation, consistent with its role in complex or atypical presentations. Despite its limited use, Meckel’s scan demonstrated 100% sensitivity in detecting ectopic gastric mucosa in our diverticulitis cases. This supports its utility in selected cases, especially those with painless rectal bleeding or suspected ectopic mucosa. However, its low usage reflects real-world limitations, including availability and false negatives in non-bleeding presentations.^[5,12,14] Future studies should focus on refining diagnostic algorithms and exploring the role of routine Meckel’s scan in selected pediatric populations.

Surgical management via laparoscopic-assisted bowel resection was uniformly adopted. This strategy is increasingly favored over simple diverticulectomy due to the risk of ectopic mucosa in the adjacent ileum and potential for missed pathology and due to associated inflammation and ischemia. This approach is increasingly favored for its diagnostic and therapeutic benefits, especially in uncertain presentations. The low rate of postoperative complications (7.14%) and short mean hospital stay (5.6 days) affirm the safety and efficacy of this approach.^[4,7,8]

In our study, 5 (17.86%) cases were incidentally discovered during unrelated surgeries, underscoring the ongoing debate about prophylactic resection. While some advocate for resection to prevent future complications^[15] others caution against unnecessary surgery in asymptomatic cases^[16]. Cullen et al.^[15] noticed that the risk of asymptomatic Meckel’s diverticulum becoming symptomatic did not decrease with age and recommended prophylactic resection. Our findings suggest that incidental Meckel’s diverticulum, especially in older children, may harbor ectopic mucosa and warrant careful intraoperative assessment.

Histopathological examination revealed gastric mucosa in 57.14%, pancreatic tissue in 4.2%, and dual ectopia in 7.14%. These findings are consistent with prior reports indicating gastric heterotopia as the most common ectopic tissue, with pancreatic tissue being rare.^[6,13] The strong association between ectopic mucosa and complications, particularly perforation (100%) and intussusception (83.3%), highlights the pathogenic role of acid secretion and mucosal ulceration. The association of ectopic tissue and symptomatic presentations, especially diverticulitis, perforation, and intussusception, emphasizes the importance of routine histopathological examination. Burjonrappa and Khaing^[13] reported that the existence of ectopic tissue is the most important factor deciding the necessity of a surgical intervention in Meckel’s diverticulum.

This study had a small sample size and was conducted in a single center. A multicenter study with a large sample size is required to validate results.

This prospective study reinforces the varied clinical manifestations of Meckel’s diverticulum in children with intestinal obstruction and intussusception being the most common. The presence of ectopic mucosa significantly correlates with complications, justifying segmental resection over diverticulectomy. Early surgical intervention, guided by clinical suspicion and supported by imaging, remains the cornerstone of management, especially in symptomatic cases. Laparoscopic or laparoscopic-assisted bowel resection remains a safe and effective treatment modality.