Fistulas are common in patients with Crohn's disease and, when associated w
ith inflammatory disease and established for several weeks, tend to be chro
nic. Perianal fistulas are the most frequent complication of, and are most
often associated with, colonic disease. Perianal fistulas commonly require
surgical resection and permanent ileostomy. Antibiotics, cyclosporine, meth
otrexate and thalidomide have been used in uncontrolled trials; only azathi
oprine, 6-mercaptopurine and infliximab have been assessed in double-blind,
placebo controlled studies. Relapse of the fistula occurs with all drugs,
unless treatment is continued long term. Each drug differs in its onset of
action and long term tolerability. An approach to fistulizing disease in Cr
ohn's disease is suggested.