What is the best course of treatment for a 6-year-old patient with persistent abdominal pain, elevated white blood cell count (leukocytosis) and neutrophils, arm pain, and worsening symptoms with recumbency, despite a normal computed tomography (CT) scan and recent Miralax (polyethylene glycol) cleanout, with a diagnosis of rhinoenteritis?

Management of Persistent Abdominal Pain in a 6-Year-Old with Leukocytosis and Rhinoenteritis

This child requires urgent reassessment with consideration for bacterial superinfection or surgical pathology, including repeat imaging if symptoms persist or worsen, along with empiric broad-spectrum antibiotics if clinical deterioration occurs, as the combination of persistent abdominal pain worsening with recumbency, elevated white count with neutrophilia, and arm pain suggests a more serious process than simple viral gastroenteritis. 1

Immediate Clinical Reassessment

The clinical picture is concerning for several reasons that warrant aggressive evaluation:

• Leukocytosis with neutrophilia in a pediatric patient with persistent abdominal pain after normal CT suggests either early surgical pathology, bacterial superinfection, or evolving intra-abdominal process 1. Laboratory tests may not accurately reflect disease severity, particularly in evolving conditions 1.

• Pain worsening with recumbency is atypical for simple gastroenteritis and raises concern for peritoneal irritation or inflammatory processes 1. This positional component combined with periumbilical pain requires careful evaluation for appendicitis, mesenteric adenitis with bacterial component, or other surgical emergencies 1.

• Arm pain in conjunction with abdominal symptoms and leukocytosis is unusual and may suggest systemic inflammatory response, bacteremia, or referred pain from diaphragmatic irritation 1.

Diagnostic Approach

Laboratory Evaluation

Obtain the following tests immediately:

• Complete blood count with differential to assess absolute neutrophil count and band forms 1. An elevated band count or I:T ratio (immature-to-total neutrophil ratio) >0.20 suggests bacterial infection 2.

• C-reactive protein (CRP) is fundamental in differential diagnosis and more sensitive than ESR for acute abdominal processes 1. Elevated CRP with leukocytosis strongly suggests bacterial etiology.

• Comprehensive metabolic panel, liver enzymes, and serum albumin to assess for electrolyte derangements, hepatic involvement, or inflammatory markers 1.

• Blood cultures if fever present or patient appears toxic 1.

Stool Studies

• Mandatory testing for Clostridioides difficile toxin, even without diarrhea, as this can present with abdominal pain and leukocytosis 1.

• Stool culture and bacterial pathogen testing to identify Salmonella, Shigella, Campylobacter, or other invasive bacterial pathogens that can cause leukocytosis 1.

Imaging Considerations

• Despite normal initial CT, repeat contrast-enhanced CT scan should be strongly considered if symptoms persist or worsen 1. CT is the most reliable exam to diagnose intra-abdominal disease and can identify complications not visible on initial imaging 1.

• Abdominal ultrasound may detect bowel wall thickening, free fluid, or appendiceal changes if CT is not immediately available 1.

Treatment Strategy

Empiric Antibiotic Therapy

If the child appears toxic, has worsening pain, persistent fever, or shows signs of clinical deterioration, initiate broad-spectrum antibiotics immediately 1:

• For suspected bacterial gastroenteritis with systemic involvement: Consider amoxicillin-clavulanate 45 mg/kg/day divided every 12 hours (based on amoxicillin component) for severe infection 3, OR a third-generation cephalosporin with metronidazole 1.

• Dosing must account for severity: For severe infections in children weighing <40 kg, use 45 mg/kg/day divided every 12 hours 3.

Supportive Care

• Bowel rest with IV hydration if bacterial enterocolitis or surgical pathology suspected 1.

• Pain management with appropriate analgesics that don't mask peritoneal signs.

• Close monitoring of vital signs, urine output, and clinical status every 4-6 hours 1.

Red Flags Requiring Surgical Consultation

Immediate surgical evaluation is needed if any of the following develop:

• Signs of peritonitis: guarding, rebound tenderness, absent bowel sounds 1.

• Persistent or worsening pain despite conservative management 1.

• Development of fever, tachycardia, or hemodynamic instability 1.

• Imaging findings suggestive of perforation, obstruction, or abscess formation 1.

Common Pitfalls to Avoid

• Do not assume viral rhinoenteritis explains all symptoms when leukocytosis with neutrophilia is present 4. Viral infections typically show lymphocytic predominance, not neutrophilia 1.

• Do not rely solely on initial normal CT scan if clinical picture worsens, as surgical pathology can evolve rapidly in children 1.

• Do not dismiss positional pain (worse with lying down) as this suggests peritoneal involvement requiring urgent evaluation 1.

• Do not delay antibiotics in a deteriorating child while awaiting culture results 1.

Follow-Up Protocol

• Daily monitoring of complete blood count and CRP until clinical improvement documented 1.

• Repeat imaging within 24-48 hours if no clinical improvement despite appropriate therapy 1.

• Surgical consultation should remain involved until surgical pathology definitively excluded 1.

The combination of persistent symptoms, leukocytosis with neutrophilia, and atypical features (arm pain, positional worsening) mandates aggressive evaluation and low threshold for intervention in this 6-year-old patient 1.