Dr.Asif Iqbal

2nd year P.G

Erythrocyte sedimentation rate (ESR) is a

non-specific test for inflammation.

It is easy to perform, widely available and

inexpensive making it a widely used

screening test

It is also used a monitoring tool for

response to treatment in conditions in

which it is raised (tuberculosis,

autoimmune diseases etc (

Basics:

The ESR test is performed in the laboratory by placing

anticoagulated blood in an upright tube (Westegren's most often).

At the end of an hour of this, the rate of the RBC sedimentation is

measured .

The ESR is governed by the balance between pro-sedimentation

factors, mainly fibrinogen, and those factors resisting

sedimentation. When an inflammatory process is present, the high

proportion of fibrinogen in the blood causes red blood cells to

stick to each other. The red cells form stacks called 'rouleaux,'

which settle faster. Rouleaux formation can also occur in

association with some lymphoproliferative disorders in which one

or more immunoglobulin are secreted in high amounts.

A-Effect of plasma protein:

Increased in the concentration of fibrinogen and Immunoglobulin's due to tissue injury will increase rouleaux formation and hence the rate of sedimentation. Plasma albumin retards sedimentation of RBCs .

B-The RBC size and number :The size and number of RBCs that show alterations in their bioconcavity, like spherocyte and sickle cells, usually do not exhibit increase rate, unless there is severe anemia. Increase red cell mass will retard the sedimentation rate e.g. polycythemia.

The initial lag phase (10m)

The phase of rapid RBC falling(40m)

The packing phase (10m)

Normal value:

ESR values tend to rise with age and are

generally higher in women. ESR is also

elevated in the black population and those

with anemia .

Adult females 0-20 mm/h

Adult males 0-15 mm/hr

Children(<10) 0-10 mm/hr

ESR is determined by the interaction between factors that promote (fibrinogen) and resist (negative charge of RBCs - that repel each other) sedimentation. Normal RBCs settle slowly as they do not form rouleaux or aggragate together. Instead, they gently repel each other due to the negative charge on their surfaces.

Increased rouleaux formation contributes to high ESR. Rouleaux are stacks of many RBCs that become heavier and sediment faster. Plasma proteins, especially fibrinogen, adhere to the red cell membranes and neutralize the surface negative charges, promoting cell adherence and rouleaux formation

*** Patient must be fasting at least 4 hours before testing.

-The blood sample must be mixed with anticoagulant agent in this test.

3.8% tri-sodium citrate solution. 0.4 ml of tri-sodium citrate is added in 2 ml of blood.

1. Mix gently with out shaking then put in the graded tube and leave it stand vertically on the stand for 1 hour.

2. Read the amount of plasma that appeared without moving it then leave it to the second hour and read another time

The aggregated RBCs in the rouleaux formation have a higher ratio of

'mass to surface area' as compared to single RBCs and hence sink

faster in plasma .

ESR of more than 100 mm/hr is

strongly associated with serious

underlying disorders like connective

tissue disease, infections and

malignancies

Requirements:

1. Westergren Pipette

2. Westergren Stand

3. Anticoagulant

Westergren pipette is open at both the ends.

It is 30 cm in length and 2.5 mm in diameter.

The lower 20 cm are marked with 0 at top

and 200 at bottom.

The anticoagulant used in this method is 3.8%

tri-sodium citrate solution. 0.4 ml of tri-

sodium citrate is added in 2 ml of blood.

Fill the pipette by sucking blood upto 0

marks and fix it vertically in Westergren

stand. Read the upper level of RBC column

exactly after 1 hr.

Requirements:

1. Wintrobe Pipette

2. Anticoagulant

3. Wintrobe Stand

Wintrobe tube is open at one side only. The

length of Wintrobe tube is 11 cm and the

diameter is 2.5 mm. The lower 10 cm are

marked. The marking is 0 at top and 100 at

bottom for ESR, and it is also used for PCV

(Packed Cell Volume).

The anticoagulant used in Wintrobe Method

is EDTA solution. 0.4 ml of anticoagulant is

required for 2 ml of blood.

With the help of long necked pasture pipette

or a special syringe, fill the Wintrobe tube

upto ’0′ mark. Place the tube in an exactly

vertical position in a Wintrobe stand. Read

the upper level of RBC column exactly after

1 hr.

Multiple myeloma

Connective tissue

Autoimmune diseases

Tuberculosis

Malignancies

Severe anemia

Drugs such as dextran, methyldopa

(Aldomet), oral contraceptives,

penicillamine procainamide,

theophylline, and vitamin A can

increase ESR, while aspirin,

cortisone, and quinine may decrease

it .

Polycythemia

Severe Leukocytosis

Sickle cell disease.

Hereditary spherocytosis

Congestive cardiac failure

Corticosteroid use

Note that sickle cell anemia and

spherocytosis have low ESR unlike

other anemias. This is due to

reduced rouleaux formation owing

to the abnormally shaped RBCs in

this condition .

Erythrocyte sedimentation rate is a non-specific test and is not diagnostic of any particular disease. It has a high sensitivity but low specificity .Never base a diagnosis solely on an ESR value, either normal or high .Interpretation of the result should always be along with the patient's clinical history, examination findings and results of other tests done.

If high ESR is encountered without any obvious reasons, patient should be reassured and the test repeated after a reasonable amount of time (a couple of months). There is no need to extensively search for an occult disease without repeating it again

ESR and C-reactive protein (CRP) are both markers of inflammation .

Generally, ESR does not change as rapidly as does CRP, either at the start of inflammation or as it goes away.

CRP is not affected by as many other factors as is ESR, making it a better marker of inflammation.

However, because ESR is an easily performed test, many doctors still use ESR as an initial test when they think a patient has inflammation .

A physician usually orders an ESR test (along

with others )to evaluate a patient who has

symptoms that suggest polymyalgia

rheumatica or temporal arteritis ,such as

headaches, neck or shoulder pain, pelvic

pain, anemia, unexplained weight loss, and

joint stiffness. There are many other

conditions that can result in a temporary or

sustained elevation in the ESR .

The ESR is an indicator in your body. Like

pain, it is giving you a warning that

something is wrong.

In most cases, the ESR will decrease over

time once the underlying inflammation is

addressed.

If you have a chronic inflammatory disease,

the ESR may fluctuate with the degree of

activity of your condition.

Thank you