Cobblestone Sign In Crohn's Disease

Deep Ulcers Caused By Crohn's Disease Cause A Distinctive Sign In The Intestine

Ulceration caused by Crohn's disease can lead to a cobblestone-like appearance in the lining of the small and large intestines. Image © Linda Bucklin

Crohn's disease and ulcerative colitis are lumped together under the umbrella term of inflammatory bowel disease (IBD). The two diseases have many aspects in common, including several signs and symptoms, and are treated with several of the same medications. 

Differences Between Crohn's And Colitis

In some cases, the differences between Crohn's disease and ulcerative colitis might seem like minutia, but they are important when it comes to treatment.

Surgical procedures are very different for ulcerative colitis and Crohn's disease. In fact, surgery done for Crohn's disease is not appropriate to treat ulcerative colitis and vice versa. It follows, therefore, that it is critical to be able to distinguish between the two diseases. One way to distinguish inflammation in the intestines in Crohn's disease from that caused by ulcerative colitis is by the so-called "cobblestone" appearance.

Cobblestones are best known as an architectural feature that are sometimes used instead of pavement. Cobblestones are used in a decorative pathway or a street, usually made of distinct pieces of stone or brick that may or may not be set into mortar. They don't present an even appearance — there are slight gradations in the color and sizes in the stone used. They often give an "old world" look and feel, and might be found in historic downtown areas.

Where cobblestones fit in with Crohn's disease is a reference to the appearance of the inflammation that Crohn's causes.

The inner lining of the intestine may develop sections that, instead of being healthy and smooth, have crevices and raised sections. This is caused by a combination of the deep ulceration and the thickening of the intestinal wall caused by the Crohn's disease. A gastroenterologist may see the cobblestone sign in the intestine during a colonoscopy or a sigmoidoscopy.

The cobblestone sign can be an important criteria during diagnosis of IBD because it is seen with Crohn's disease, but is not seen in the colon of people who have ulcerative colitis. There have also been reports of people with Crohn's disease who have mouth ulcers (aphthous stomatitis) that also exhibit the cobblestone sign.

The cobblestone appearance in the lining of the colon can also occur with other digestive conditions, such as Hirschsprung disease (which is a type of bowel obstruction seen in newborns) and eosinophilic gastritis (an uncommon but self-limiting condition). Other tissues in the body may also appear to look like cobblestones when affected by a disorder or a disease.

While the cobblestone sign is a good indicator of the presence of Crohn's disease, it should also be noted that it does not occur in every single case. It might actually appear in fewer than half of all people who have Crohn's disease, but when the cobblestone appearance is there, it is a way for physicians to tell Crohn's disease apart from ulcerative colitis.


Salek H, Balouch A, Sedghizadeh PP. "Oral manifestation of Crohn's disease without concomitant gastrointestinal involvement." Odontology. 2013 May 8. 22 Apr 2014.

Greenberg GR, Fedorak RN, Thomson ABR. "First Principles of Gastroenterology: The Basis of Disease and an Approach to Management. Fifth Edition." Canadian Association of Gastroenterology. 2011. 22 Apr 2014.

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