See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/262191374

Demographic Disparities of Children Presenting with Symptomatic Meckel's

Diverticulum in the United States

Article  in  Pediatric Surgery International · May 2014

DOI: 10.1007/s00383-014-3513-y · Source: PubMed

CITATIONS READS

25 206

5 authors, including:

Shawn D St. Peter

Children’s Mercy Kansas City
552 PUBLICATIONS   13,934 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

ATOMAC Solid Organ Injury View project

All content following this page was uploaded by Shawn D St. Peter on 18 September 2014.

The user has requested enhancement of the downloaded file.

Pediatr Surg Int (2014) 30:649–653
DOI 10.1007/s00383-014-3513-y
ORIGINAL ARTICLE
Demographic disparities of children presenting with symptomatic
Meckel’s diverticulum in children’s hospitals
Hanna Alemayehu • Matt Hall • Amita A. Desai
Shawn D. St. Peter • Charles L. Snyder
Accepted: 22 April 2014 / Published online: 9 May 2014
Ó Springer-Verlag Berlin Heidelberg 2014
Abstract
Purpose Most of the literature about Meckel’s divertic-
ulum (MD) consists of single institutional longitudinal case
series. We queried the pediatric hospital information sys-
tem (PHIS) database to obtain information about the epi-
demiology of MD from a large number of children at
geographically diverse locations.
Methods After IRB approval, the PHIS database was
queried over a 9-year period for de-identified patients with
both ICD-9 diagnoses of MD and a procedure code for
Meckel’s diverticulectomy. Data from five hospitals were
excluded due to incomplete information.
Results 4,338,396 were children admitted during the
study interval; 945 had a symptomatic MD. The incidence
decreased with age: 56.4 % were under 5 years old, 26.8 %
were between the ages of 6–12 years, and 16.8 % were
older than 12 years. 74 % were male, which was signifi-
cantly higher than the PHIS population (53.8 % male,
P \ 0.0001). Caucasians are over-represented in the
symptomatic MD group (63.4 %) compared to the rest of
the PHIS population (48.1 %, P \ 0.0001).
Conclusions According to the PHIS data, there appears to
be significant gender and race influence on symptomatic
MD. Males present more commonly, as do non-Hispanic
White patients, while it is less common among non-His-
panic Black patients.
H. Alemayehu
A. A. Desai
S. D. St. Peter
C. L. Snyder (&)
Section of General Surgery, Department of Surgery,
The Children’s Mercy Hospital, 2401 Gillham Road,
Kansas City, MO 64108, USA
e-mail: csnyder@cmh.edu
M. Hall
Children’s Hospital Association, Overland Park, KS, USA
•
Keywords Meckel’s diverticulum
Race
Gender

Disparity
Introduction
The presentation of Meckel’s diverticulum (MD) ranges
from an incidental finding in an asymptomatic patient to
life-threatening symptomatology that may include bleed-
ing, obstruction, inflammation, or other less common
variants. Although not rare, symptomatic MD is infrequent
enough that most of the literature consists of single insti-
tutional longitudinal case series. Information regarding
incidence, age–sex distribution, clinical presentation and
other aspects of the natural history of the finding are based
on these limited case reports and case series.
We queried the pediatric hospital information system
(PHIS) database which is more broadly representative of
the pediatric patient population in the United States to
better establish demographic information regarding MD.
The PHIS database is a comprehensive pediatric database
containing financial, administrative and clinical data for
more than six million patient cases from 44 children’s
hospitals, established and operated by the Children’s
Hospital Association. Our goal was to obtain information
about the epidemiology of MD from a large number of
children at geographically diverse locations.
Methods
After obtaining Institutional Review Board exemption
(#12050264), the PHIS database was queried for de-iden-
tified patients with both ICD-9 diagnoses of MD and
associated symptoms, and a procedure code for Meckel’s
123
650 Pediatr Surg Int (2014) 30:649–653

Table 1 Demographic Category Sub-category Rest of PHIS population (%) Symptomatic MD (%) P value
differences between patients
with symptomatic Meckel’s Age 0–5 years 2,411,490 (55.6) 533 (56.4)
diverticulum (MD) and the rest
6–12 years 926,665 (21.4) 253 (26.8)
of the PHIS population
[12 years 999,296 (23) 159 (16.8) \0.0001
Sex Male 2,332,104 (53.8) 699 (74) \0.0001
Female 2,004,853 (46.2) 246 (26)
Race Non-Hispanic White 2,086,282 (48.1) 599 (63.4) \0.0001
Non-Hispanic Black 884,681 (20.4) 44 (4.7)
Hispanic 785,746 (18.1) 155 (16.4)
Asian 114,944 (2.7) 37 (3.9)
Other 465,798 (10.7) 110 (11.6)
Payor Government 2,163,879 (49.9) 383 (40.5) \0.0001
Private 1,605,387 (37) 395 (41.8)
Other 568,185 (13.1) 167 (17.7)

Fig. 1 Age distribution of the

PHIS population (MD Meckel’s
diverticulum)

diverticulectomy. Data from a 9-year interval (2004–2012)
were analyzed for age, payor, ethnicity, and presenting
symptoms. Data from five participating hospitals were
excluded due to incomplete information. Data were eval-
uated by year for trends, and in aggregate. US Census data
from 2010 were used as comparative demographic data. A
P value of \0.05 was deemed statistically significant.
Results
There were a total of 4,338,396 children admitted during
the study interval, of whom 53.8 % were male. The ethnic
distribution of the group as a whole was: 48.1 % Cauca-
sian, 20.4 % African-American, 18.1 % Hispanic, 2.7 %,
Asian, and 10.7 % other.
There were 2,389 children with a diagnosis code of MD,
945 of whom had symptomatic MD. This equates to about
1 in 4,500 hospital admissions for symptomatic MD. There
were some significant demographic differences between
those with symptomatic MD and those without, as seen in
Table 1. The incidence decreased with age: 56.4 % were
under 6 years of age (n = 533), 26.8 % were between the
ages of 6–12 years (n = 253), and 16.8 % were older than
12 years of age (n = 159). The symptomatic MD group
had significantly fewer in the [12 years age group, and
more in the 6–12-year age group than the remaining PHIS
population; P \ 0.0001 (Fig. 1).
74 % of the patients with symptomatic MD were
male, significantly higher than in the rest of the PHIS
population (P \ 0.0001). Ethnic distribution was 63.4 %
Caucasian, 4.7 % African-American, 16.4 % Hispanic,
3.9 % Asian, and 11.6 % other. Caucasians presented
with a symptomatic MD far more than expected based
on the overall PHIS population; P \ 0.0001 (Fig. 2). The
proportions of Asian and Hispanic patients with MD
were equivalent to the proportion of PHIS patients that
were Asian and Hispanic.

123
Pediatr Surg Int (2014) 30:649–653 651

Fig. 2 Ethnic distribution of

symptomatic Meckel’s
diverticulum (MD) in the PHIS
population

Patients with symptomatic MD were more likely to have Table 2 Symptoms in patients with Meckel’s diverticulum
private payors (41.8 %) compared to the rest of the PHIS
Symptom Overall symptomatic
population (37 %); P \ 0.0001. Of the 945 patients with Meckel’s (n = 945)
symptomatic MD, bowel obstruction was the most com- (%)
mon presenting symptom (60.1 %). Further presenting
Bowel obstruction 60.1
symptoms included gastrointestinal bleeding, inflammatory
Bleeding 35.6
symptoms and other (Table 2).
Inflammatory 8.4
Other 0.4
Discussion

The accepted incidence of MD in the general population is
approximately 2 %, based on autopsy studies [1–4],
although the incidence of symptomatic presentation has
been more difficult to elucidate. Several single institution
series and retrospective reviews have studied the natural
course of MD and determined that the incidence of
symptomatic presentation ranges between 17–54 % [5, 7],
and one large epidemiologic study showed the incidence of
developing complications from MD to be as low as 6.4 %
[8]. In patients undergoing resection of MD, the incidence
of symptomatic MD is higher ranging betwen 16–89 % [9–
14]. Many studies in the literature also evaluated age–sex
distribution and various types of symptomatic presentation.
Our study used the pediatric hospital information system
database and found that symptomatic MD accounted for
about 1 in 4,500 hospital admissions. There was a higher
incidence of symptomatic MD in males, and a dispropor-
tionately higher incidence in Caucasians was also noted,
while African-Americans were disproportionately less
often affected.
Administrative databases, such as the PHIS database,
are well suited to epidemiologic reviews. This paper has
several limitations. Information about individual cases is
lacking. Coding inaccuracies are likely. There are a

123
652
Table 3 Comparison of the Group Non-Hispanic
PHIS population to US census White
data
PHIS (n) 2,086,881
PHIS (%) 48.10
US Census 178,750,000
2010 (n)
US Census 57.85
2010 (%)
substantial number of children whose symptoms or eth-
nicity is not known. Additionally, the PHIS database may
not be representative of the wider population of children
with MD, since it captures only patients admitted to chil-
dren’s hospitals, thereby missing children managed in non-
children’s hospitals who would likely be older or more
acutely ill. Furthermore, the database only includes patients
admitted to 44 children’s hospitals, which represents only
about a third of the children’s hospitals in the country.
Although the database only partially represents the chil-
dren’s hospitals in the country, data are included from
hospitals encompassing 17 of 20 major metropolitan areas,
covering the full range of geographic regions in the US
[15].
This study is one of the larger reviews of symptomatic
patients with MD covering a diverse geographic region,
and likely is a good representation of pediatric symptom-
atic MD in the United States. Although this review does not
include a large portion of patients with MD who had no
identifiable symptoms and likely underwent incidental
diverticulectomies, the data did identify the most common
presentation which is helpful in guiding clinical care.
The male predominance in symptomatic MD found in
our study has been previously described [5, 7, 12], with the
usual gender ratio being 3:1 male to female. The racial
predispositions found in this study are not previously
described and represent a new epidemiologic finding for
symptomatic MD. Caucasians were more likely to have
symptomatic MD, whereas African-Americans were dis-
proportionately less affected.
Clearly the finding of racial disparities depends to some
degree on the population available for study. Assume
Disease X is absolutely known to have an incidence of 10
in 100 Asians versus 1 in 100 Whites (10: 1 Asian to
White). If our study database were an exact reflection of
the general population from which it is drawn (for sim-
plicity assume 95 % White and 5 % Asian), an analysis
would show: for 100,000 patients in the database: 95 %
White means 95,000 9 0.01 = 950 cases, and 5,000
Asians 9 0.10 = 500 cases. Pearson’s Chi squared =
2,692.49 (P \ 0.0001).
Now assume there are instead five times more Asians in
our database than in the general population (i.e. 25 %
123
Pediatr Surg Int (2014) 30:649–653
Non-Hispanic Hispanic Asian Other Total
Black
884,725 785,901 114,981 465,908 4,338,396
20.40 18.10 2.70 10.70
38,000,000 50,550,000 14,860,000 26,840,000 309,000,000
12.30 16.36 4.81 8.69
Asian and 75 % White). For 100,000 patients : 75 % White
means 75,000 9 0.01 = 750 cases, and 25,000 Asians 9
0.10 = 2,500 cases. Pearson’s Chi squared = 4,830.05
(P \ 0.0001). Although the P values are both quite low,
there is a huge statistical difference.
We therefore compared the racial composition of the
patients in the PHIS database to the US Census data from
2010 (Table 3). Since the PHIS database consists of pedi-
atric inpatient admissions, it represents children that have a
medical problem severe enough to warrant hospitalization.
There is extensive literature describing disparities in race
and/or socioeconomics as regards many pediatric condi-
tions (asthma, trauma, etc.). It would be likely that any
database collecting information on sick children would
differ from the census data representing primarily healthy
children. In fact, as might be expected, non-Hispanic Black
patients were overrepresented in the PHIS database
(20.4 %) compared to the US census data (12.3 %),
reflecting the disparities seen in many general pediatric
ailments. This would lead one to expect a similar over-
representation in the symptomatic Meckel’s group; how-
ever, we observed the opposite, where non-Hispanic White
patients were overrepresented in the symptomatic Meckel’s
group.
One may also argue that selected patients were trans-
ferred to the PHIS hospitals accounting for the ethnic
disparity. Patients of lower socioeconomic status and with
no insurance or with Medicaid coverage are typically those
more likely to be transferred [16], but this is not what we
found. In fact, patients with symptomatic MD were equally
likely to have private or government payors, whereas the
rest of the patients in the PHIS population were more likely
to have government payors. This may be a reflection of the
racial and associated socioeconomic disparities.
The symptoms most commonly associated with MD in
children are gastrointestinal bleeding, small bowel obstruction
and inflammation of the diverticulum [5–7, 9–14, 17–19],
although these have been described to have different inci-
dences based on age [9, 17]. Analysis of presenting symptoms
in children with MD in our study, not accounting for race or
age, showed that bowel obstruction was the most common
complication overall as noted in several previous studies [6, 7,
10, 12, 13, 18, 20], although this has been disputed in other
Pediatr Surg Int (2014) 30:649–653
studies [5, 9, 11, 14, 18]. The previous studies in the literature
show a wide diversity in the distribution of presenting
symptoms, and many include a heterogeneous population in
terms of age [5–13, 17–20].
Conclusions
Caucasians are more likely to present with symptomatic
MD, while African-Americans are disproportionately less
often affected in our study population. Patients with MD
are more likely to have a private payor, and less likely to
have a government payor, than the rest of the PHIS pop-
ulation. This study suggests the possibility of racial and
socioeconomic disparities in the incidence of symptomatic
MD in children.
Conflict of interest The authors declare that they have no conflicts
of interest.
References
1. Christie A (1931) Meckel’s diverticulum: a pathologic study of
63 cases. Am J Dis Child 42:544–553
2. Kittle CF, Jenkins HP, Dragstedt LR (1947) Patent omphalo-
mesenteric duct and its relation to the diverticulum of Meckel.
Arch Surg 54:10–36
3. Harkins HH (1933) Intussuception due to invagination of Mec-
kel’s diverticulum; report of two cases with a study of 160 cases
collected from the literature. Ann Surg 98:1070–1095
4. Jay GD, Margulis RR, McGraw AR et al (1950) Meckel’s
diverticulum; a survey of 109 cases. Arch Surg 61:158–169
5. Rutherford RB, Akers DR (1966) Meckel’s diverticulum: a
review of 148 pediatric patients, with special reference to the
pattern of bleeding and to mesodiverticular vascular bands. Sur-
gery 59(4):618–626
View publication stats
653
6. Soltero MJ, Bill AH (1976) The natural history of Meckel’s
diverticulum and its relation to incidental removal. Am J Surg
132:178–203
7. Mackey WC, Dineen P (1983) A 50 year experience with Mec-
kel’s diverticulum. Surg Gynecol Obstet 156:56–64
8. Cullen JJ, Kelly KA, Moir CR et al (1994) Surgical management
of Meckel’s diverticulum. An epidemiologic, population-based
study. Ann Surg 220(4):564–569
9. Vane DW, West KW, Grosfeld JL (1987) Vitelline duct anom-
alies. Arch Surg 22:542–547
10. Bemelman WA, Hugenholtz E, Heij HA et al (1995) Meckel’s
diverticulum in Amsterdam: experience in 136 patients. World J
Surg 19:734–737
11. Groebli Y, Bertin D, Morel P et al (2001) Meckel’s diverticulum
in adults: retrospective analysis of 119 cases and historical
review. Eur J Surg 167:518–524
12. Pinero A, Martinez-Barba E, Canteras M et al (2002) Surgical
management and complications of Meckel’s diverticulum in 90
patients. Eur J Surg 168:8–12
13. Park JJ, Wolff BG, Tollefson MK et al (2005) Meckel divertic-
ulum. Ann Surg 241:529–533
14. Menezes M, Tareen F, Saeed A et al (2008) Symptomatic Mec-
kel’s diverticulum in children: a 16-year review. Pediatr Surg Int
24:575–577
15. Narus SP, Srivastava R, Gouripeddi R et al (2011) Federating
clinical data from six pediatric hospitals: process and initial
results from the PHIS ? consortium. AMIA Annu Symp Proc
2011:994–1003
16. Durbin DR, Giardino AP, Shaw KN et al (1997) The effect of
insurance on likelihood of neonatal interhospital transfer. Pedi-
atrics 100(3):E8
17. Tseng YY, Yang YL (2009) Clinical and diagnostic relevance of
Meckel’s diverticulum in children. Eur J Pediatr 168(12):
1519–1523
18. Ymaguchi M, Takeuchi S, Awazu S (1978) Meckel’s diverticu-
lum. Investigation of 600 patients in Japanese literature. Am J
Surg 136(2):247–249
19. Stone PA, Hofeldt MJ, Campbell JE et al (2004) Meckel diver-
ticulum: 10-year experience in adults. South Med J
97(11):1038–1041
20. St-Vil D, Brandt ML, Panic S et al (1991) Meckel’s diverticulum
in children: a 20-year review. J Pediatr Surg 26(11):1289–1292
123