This topic is about managing two abdominal fistulas that are located under an ostomy barrier. The person dealing with this situation is looking for advice on how to protect the fistula openings, prevent leakage and odor, and maintain a secure seal while working. Here are some helpful insights and advice:

1. Current Challenges:
- Protecting both fistula openings.
- Preventing leakage and odor.
- Keeping the flange sealed while working.

2. Medical Status:
- Started on oral antibiotics: Flagyl (metronidazole) and Cipro (ciprofloxacin).
- Scheduled for a GI appointment to change Crohn’s medication.
- Remicade is not an option due to a past yeast infection; Humira was used before the ostomy.
- History of surgical treatment for rectal fistulas since 1986.

3. Practical Pouching Tips:
- Consider whether to leave the second fistula open, cover it with the barrier, cut it out of the wafer, or dress it separately.
- Unsure if cutting a second hole in the wafer could cause an abscess.
- The second fistula has enlarged and is being packed with gauze as advised by a doctor.
- Looking for ways to control odor while teaching.
- The first fistula is shrinking, but the second continues to drain.

4. Aloe Vera Poultice:
- Slice open a fresh aloe leaf, place the gooey side over the fistula opening, secure with a Band-Aid, and apply the wafer over it.
- Reported to help close the skin opening within a month and soothe irritated stoma tissue.

5. Fill the Fistula With Ostomy Paste:
- After draining the tract, inject a small amount of ostomy adhesive paste into the tunnel until full, then apply the flange.
- The exudate will dissolve the paste over time; clean out residue during appliance changes.
- Reported to heal fistulas to shallow depressions within three weeks.

6. Silver Dressing + Hydrocolloid Cover:
- Use a strip of Aquacel Ag dressing, leaving a tail outside the opening, and cover with a custom-cut hydrocolloid dressing before applying the wafer.
- Provides antimicrobial action and absorbs drainage.
- Requires daily appliance changes.
- Supplement with vitamins A, C, and zinc to support healing.

7. Medication / Surgical Considerations:
- Remicade is effective at closing fistulas but has infection risks if restarted after a long break.
- Surgical repair is a reliable option if medical therapy or topical measures fail.

8. General Tips:
- Use stool softeners to keep stool soft while antibiotics work.
- Gently manipulate the skin to drain tracts before filling or dressing them.
- Address odor early; even simple gauze packing with a secure seal can help limit smell in a classroom setting.