What is the next step in managing an 8-year-old female with suspected anxiety-related abdominal pain episodes and constipation, who has leukopenia (low White Blood Cell Count), mild polycythemia (elevated Packed Cell Volume), and normal hemoglobin (HB) levels?

From the Guidelines

The patient's low white blood cell count, particularly the neutropenia and lymphopenia, requires further evaluation, but given the clinical context of suspected anxiety-related abdominal pain episodes and constipation, a multidisciplinary approach including dietary counseling and consideration of brain-gut behavior therapies should be prioritized. The patient's blood results show a white blood cell count of 3.4 x10^9/L (below the normal range of 4.0-11.0), with both neutrophils (1.6 x10^9/L) and lymphocytes (1.3 x10^9/L) below their respective reference ranges. While the hemoglobin and platelets are normal, this leukopenia requires investigation as it could represent a transient viral suppression of bone marrow, an early manifestation of an autoimmune condition, or other pathology.

Given the patient's symptoms of abdominal pain and constipation, which may be related to anxiety, a comprehensive approach to managing irritable bowel syndrome (IBS) and mental health comorbidity should be considered, as outlined in recent guidelines 1. This approach includes master patient-friendly language for discussion of the gut-brain axis, adjusting the duration and frequency of assessment and treatment visits, and being familiar with the threshold for referral to specialist clinicians.

Key considerations in the management of IBS with constipation include dietary counseling, with a focus on patient-centered and tailored approaches, and the potential use of laxatives, such as osmotic laxatives (e.g., polyethylene glycol) or stimulant laxatives (e.g., senna), as outlined in recent reviews 1. Brain-gut behavior therapies, including cognitive behavioral therapy and gut-directed hypnotherapy, have also been shown to be effective in managing IBS symptoms and improving quality of life 1.

In terms of next steps, a multidisciplinary approach, including referral to a gastroenterologist, specialist gastroenterology dietitian, or gastropsychologist, should be considered, depending on the patient's specific needs and the severity of their symptoms. The patient's blood abnormalities should be further evaluated, with consideration of repeating the complete blood count and potentially proceeding with additional testing, including a peripheral blood smear and assessment for potential viral infections. However, the primary focus should be on addressing the patient's gastrointestinal symptoms and mental health comorbidity, with a comprehensive and integrated approach to care.

From the FDA Drug Label

STOP USE AND ASK A DOCTOR IF • you have rectal bleeding or your nausea, bloating, cramping or abdominal pain gets worse. These may be signs of a serious condition. • you get diarrhea • you need to use a laxative for longer than 1 week

The patient has abdominal pain episodes and constipation. Given the patient's symptoms and the fact that the white cell count is low (3.4), it would be prudent to consult a doctor before starting any new medication, including polyethylene glycol (PO) 2. The low white cell count may indicate an underlying condition that needs to be addressed. Additionally, the patient's PCV is high (0.43), which may also require further evaluation.

• Key considerations:
  • Abdominal pain episodes
  • Constipation
  • Low white cell count
  • High PCV
• Next steps: Consult a doctor to discuss the patient's symptoms and laboratory results before starting any new treatment.

From the Research

Patient's Blood Test Results

The patient's blood test results show:

• Hemoglobin (HB) level is within the normal range (144 g/L)
• White Cell Count is slightly below the normal range (3.4)
• Neutrophils are slightly below the normal range (1.6)
• Lymphocytes are slightly below the normal range (1.3)
• Platelet count is within the normal range (229)

Constipation Treatment

For the treatment of constipation, the following options can be considered:

• Polyethylene glycol (PEG) with or without electrolytes, as it has been shown to be effective in treating functional constipation in children and adults 3, 4
• Dietary fiber supplementation and stimulant and/or osmotic laxatives, as recommended by the guidelines for the management of chronic constipation 5
• Intestinal secretagogues and/or prokinetic agents, if necessary, as recommended by the guidelines for the management of chronic constipation 5

Polyethylene Glycol (PEG) Treatment

PEG with or without electrolytes has been shown to be effective and safe in treating chronic constipation in children and adults:

• A study found that PEG with or without electrolytes was more efficacious than placebo in treating functional constipation in pediatric patients 3
• Another study found that PEG formulations with or without electrolytes had similar effectiveness, safety, and acceptability in treating chronic constipation in children 4
• A post hoc analysis of a clinical trial found that PEG 3350 was effective and safe in treating chronic idiopathic constipation in adults 6

Adherence to PEG Treatment

Adherence to PEG treatment in children with functional constipation is associated with:

• Parental illness perceptions, satisfaction with treatment, and perceived treatment convenience 7
• Treatment inconvenience, dissatisfaction with treatment, and the emotional impact of functional constipation may negatively influence treatment adherence 7