Introduction Inflammatory bowel disease (IBD) is known as a chronic complex inflammatory condition of the gastrointestinal tract (GI), characterized by a disrupted mucosal structure, altered gut microbial composition, and systemic biochemical abnormalities which can lead to significant morbidity. The exact etiology of IBD is not known clearly, however, the most dominant hypothesis suggests that IBD is caused by exaggerated immune response, triggered by environmental factors towards the altered gut microbiota or pathogenic microorganisms in a genetically prone host(3) Gut microbiota alteration (dysbiosis) is considered to be a novel factor involved in the pathogenesis of IBD. (3)

Here we presented a young Afghan male who has been evaluated for anemia and went through anemia work up. Through his work ups there were multiple localized ulcers in sigmoid colon represented crohn‘ s disease. Terminal ileum could not be intubated due to dolichocolon in his first colonoscopy. Pathology showed crypt destructive colitis, chronic inflammation suggestive for IBD.Mesalamin and prednisolone have been initiated but the patient didn’t respond well to treatment of Crohn s disease and his anemia was resistant. Other complementary investigation started after 6 months of treatment.MR enterography showed very large and dilated sigmoid. The second colonoscopy again showed multiple discrete localized ulcers in sigmoid, Terminal ileum was intubated and was normal. Surgery was performed due to report of MR enterography.Surgons reported very bad odor during surgery. They also found fecal stasis and localized ulceration in the sited of a twisted sigmoid. Sigmoid was resected. Pathology revealed patchy chronic colitis, increased lymphoplasma cells infiltration in lamina propria, and basal plasmacytosis. Also scattered microvascular thrombosis were identified. Based on histology ischemic colitis was also proposed but still we could not rule out the possibility of crohns disease. Patient did well after surgery and follow up colonoscopy showed no evidence of recurrence. Since there are multiple differential diagnosis for Crohn s disease, any crohn s like pathology does not necessarily indicate crohn s disease. In this patient a twisted and dilated sigmoid and chronic fecal stasis caused dysbiosis which resulted in inflammatory changes in sigmoid that was completely like crohn disease.

Conclusion It is important to consider multiple differential diagnosis for establishment of crohn disease .Although pathologic and endoscopic findings of this patient was highly suggestive for crohn disease,but the main cause of his problems was fecal stasis .The pathologic changes of his colonic mucosa which was completely similar to crohn disease could be an indicative of a pathophysiologic pathway for crohn disease which goes through dysbiosis and changes in gut microbiota.