Medical Management:

Tramadol
Tramadol (Ultram, Tramal, others below) is a centrally-acting analgesic, used in
treating moderate to moderately severe pain. The drug has a wide range of
applications, including treatment for restless leg syndrome, acid reflux,
and fibromyalgia. It was developed by the pharmaceutical company Grünenthal
GmbH in the late 1970s.

Tramadol possesses weak agonist actions at the μ-opioid receptor, releases serotonin,

and inhibits the reuptake of norepinephrine.
Uses

Tramadol is used similarly to codeine, to treat moderate to moderately severe pain and
most types of neuralgia, including trigeminal neuralgia. Tramadol is somewhat
pharmacologically similar to levorphanol (albeit with much lower μ-agonism), as both
opioids are also NMDA-antagonists which also have SNRI activity (other such opioids to
do the same are dextropropoxyphene (Darvon) & M1-like
molecule tapentadol (Nucynta, a new synthetic atypical opioid made to mimic the
agonistic properties of tramadol's metabolite, M1(O-Desmethyltramadol). It has been
suggested that tramadol could be effective for alleviating symptoms of depression,
anxiety, and phobias because of its action on the noradrenergic and serotonergic
systems, such as its "atypical" opioid activity. However, health professionals have not
endorsed its use for these disorders, claiming it may be used as a unique treatment
(only when other treatments failed), and must be used under the control of a
psychiatrist.
FORGRAM
Generic Name: Ceftriaxone
PPD Drug Anti-infectives/ Antibiotics/ Cephalosporins/ 3rd Generation
Classification: Cephalosporin
Prescription Drug: Yes
Indications: Treatment of susceptible infections including chancroid,
gastroenteritis (invasive salmonellosis, shigellosis),
gonorrhea, Lyme disease, meningitis (including
meningococcal magnetism prophylaxis), septicemia, surgical
infection (prophylaxis), syphilis, typhoid fever, Whipple's
disease.
Recommended For dosage information of prescription medicine, please
Dosage: consult with your doctor.
Precaution: Use w/ caution in patients w/ history of GI disease.
Nephrotoxicity has been reported following concomitant
administration w/ aminoglycosides. Rare occurrence of
alterations in prothrombin especially w/ patients having
impaired Vitamin K synthesis or low Vitamin K stores.
Pregnancy & lactation.
Side Effect: Pain, induration, phlebitis after IV administration, rash,
diarrhea, eosinophilia, casts in urine, thrombocytosis,
leukopenia. Elevation of aspartate transaminase, alanine
transaminase, BUN & creatinine.
Preparations: Powd for inj IM/IV 500 mg (P514.64), 1 g (P904.75).
Manufacturer: United Laboratories, Inc.

Surgical Management:

Fistulotomy/FistulectomyThere is a direct relationship between incontinence and the

amount of sphincter muscle divided. The goal of surgical treatment is thus two fold- to
eradicate the suppurative( pus forming) process permanently without compromising
anal continence

Conventionally Surgery- Fistulutomy/Fistulectomy has been the mainstay of treatment.

In this surgery, the fistula tract is laid open by cutting out the whole tract with knife. This
leads to a large wound from the anal opening to the buttock . Understandably this
leaves the patient with lot of pain in the post operative period. The patient needs
hospitalization for 4-8 days and requires dressings for this wound for 4-6 weeks .The
patient obviously is off the work for few weeks. In spite of all these difficulties, this
surgery is associated with a high recurrence rate. Other known methods such as seton
treatment and fibrin glue method have also been not widely accepted due to
requirements of repeated follow-up visits and high recurrence rates.

In high fistula(the fistulae going above the Rectal sling), the treatment is even more
complex. It requires 3 operations in a staged manner. In the first stage, the anal opening
is made in the abdomen wall called Diverting Colostomy (The fecal matter comes
through an artificial intestinal opening created on abdomen wall with a pouch fitted over
it). In the second operation, the fistula is operated upon by cutting it out  in the same
manner as described above. In the third operation, the Colostomy is closed. The whole
procedure takes about few months time. In spite of all this, this operation had high
recurrence rates and had the inherent risk of the most dreaded complication- Bowel
Incontinence (Loss of control over bowel movements). So treating high fistula has been
a nightmare for both surgeons and the suffering patients alike.