Distinction between cryptoglandular and Crohn’s fistulas may be difficult, but is important to guide treatment. Although the pathogenic mechanisms are very different, some patients may remain undiagnosed when the clinical presentation is not very clear for Crohn’s disease. Usually the complex tracts associated to Crohn’s disease are located in atypical locations and have a poor healing rate, regardless of the utilized treatment. Patients usually have constant anal pain that can be maximized during evacuation, fever can be present, but interestingly, the external fistula openings and the perianal skin are seldom painful. (Fleshman and Tay 2014) In the evaluation process, active disease in the colon and small bowel should be ruled out as the persistence of the inflammatoryprocessisassociated with the maintenance of the perianal fistula disease. Another specificcharacteristic of the Crohn’s fistula patients is the development of atypical skin tags which can help to establish the diagnosis, as the pathognomonic non-caseating granulomas can be demonstrated. In addition t o the skin tags, swelling, induration, and redness of the perianal skin can be seen, as well as purulent discharge and multiple external openings (Fig. 1).