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. 

However, there are some significant difference between the two diseases that have a direct effect on how they are approached.

One of the characteristics of Crohn's disease that's not found in ulcerative colitis is called the cobblestone sign. This is because Crohn's disease causes a different kind of inflammation than ulcerative colitis does, which leads to the parts of the intestine that are inflamed taking on a distinct appearance resembling cobblestones. 

Differences Between Crohn's And Ulcerative Colitis

In some cases, the differences between Crohn's disease and ulcerative colitis might seem like minutia, but telling the difference between the two is important when it comes to treatment. There are several medications that are used to treat both diseases, but there are others that are only approved to treat one, or have shown to be more effective for only one.

Surgical procedures are very different for ulcerative colitis than they are for Crohn's disease. In fact, surgery done for Crohn's disease is not appropriate to treat ulcerative colitis and vice versa.

 A resection of the colon wouldn't be done for ulcerative colitis because the colitis will return in the part of the colon that is left. For ulcerative colitis, the entire colon is removed. For Crohn's disease, the surgery of choice for ulcerative colitis, ileoanal pouch anal anastomosis (IPAA) or j-pouch surgery, is not usually done.

This is because Crohn's disease tends to recur in the j-pouch, and that would make pouch failure a possibility. Removing the j-pouch would mean not only more surgery, but a loss of more bowel. 

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 an architectural feature that are used in a decorative pathway or a street. They don't present a smooth, even appearance—there are slight gradations in the color and sizes in the stone used. 

Cobblestone Sign in Crohn's Disease

​Cobblestones come up when talking about Crohn’s disease because of the similar appearance the intestine can take on because of related inflammation. The inner lining of the intestine may develop sections that  have crevices and raised sections  instead of being healthy and smooth. 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 for distinguishing the form of that is IBD present. 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). There are other tissues in the body that may have the  cobblestone appearance when affected by inflammation caused by a disorder or a disease.

A Note From Verywell

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 the intestines of every single person who has the disease. 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 one more tool that physicians can use to diagnosed Crohn's disease, or 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.

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.