University of Diyala/ College of Medicine

Department of Physiology
Physiology Lab

Erythrocyte Sedimentation Rate (ESR)

Dr. Asmaa Abbas Ajwad

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February 22nd 2021
 Outlines

• Objectives of the Experiment

• Introduction, Mechanism, and Principle

• Methods of Determination ESR

• Procedure

• Clinical Significance

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 Objectives

1 To know how to measure Erythrocyte Sedimentation

Rate (ESR).

To get an idea about the mechanism and principle of

2 ESR.

To recognize the clinical value of ESR.

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ESR

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 Introduction
 Erythrocyte Sedimentation Rate (ESR) is a common hematological test
for nonspecific detection of inflammation that may be caused by infection,
some cancers and certain autoimmune diseases.
 ESR can be defined as a measurement of the rate at which the RBCs
(erythrocytes) settle from the plasma in anticoagulated blood.
 It measures the amount of inflammation in your body.
 It is non specific test ,meaning that it does not tell your doctor exactly
where the inflammation is occurring in the body, or what is causing it, and
also because it can be affected by other conditions besides inflammation.
Thus, ESR is typically used in conjunction with some other tests.
• It is used an initial screening tool and also as a follow up test to monitor
therapy and progression or remission of disease.
• ESR is helpful in diagnosis of two specific inflammatory diseases :
temporal arteritis and polymyalgia rheumatica.
• The ESR test is easy to perform and inexpensive.
• In general , normal range:
0-10 mm/hr in adult men
0-15 mm/hr in adult women
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 Introduction
 However, new studies have reported the following as normal
ESR test results:

Women under age 50 should have an ESR under 20 mm/hr.

Men under age 50 should have an ESR under 15 mm/hr.

Women over age 50 should have an ESR under 30 mm/hr

Men over age 50 should have an ESR under 20 mm/hr.

Newborns should have an ESR under 2 mm/hr.

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 Introduction
ESR is determined by the interaction between factors
that promote (fibrinogen) and factors that resist
(negative charge of RBC) sedimentation.

Normally, RBCs settle down slowly as they do not

form rouleaux. Instead, they gently repel each other
due to the negative charge on their surface.

Rouleaux are stacks of many RBCs that become

heavier and settle down faster.

Plasma proteins, especially fibrinogen, adhere to the

red cell membranes and neutralize the surface
negative charges, promoting cell adherence and
rouleaux formation.
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 Mechanism
ESR is directly proportional to the weight of the cell
aggregates and inversely proportional to the surface
area.

• To summarize: RBCs sediment by rouleaux formation, the RBCs aggregate

one on the top of each other which will increase the speed of sedimentation.
When an inflammatory process is taking place in the body, the high proportion
of fibrinogen in the blood causes RBCs to stick on each other. The RBCs form
stacks called “rouleaux” which settle faster. rouleaux formation can also occur
in association with some lymphoproliferative disorders in which one or more
immunoglobulins are secreted in high mounts.

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Rouleaux Formation and how it looks like under microscope
 Some Important Notes
ESR and CRP (C-reactive protein) are both markers of inflammation.
Generally, ESR does not change as rapidly as CRP either at the start of
the inflammation or as it goes away. CRP is not affected by many factors
as ESR does making it a better marker of inflammation. However,
because ESR is easily performed test, many doctors still use it as an
initial test when they suspect that the patient may have inflammation.
If ESR got elevated, it is typically a result of globulin or
fibrinogen. The doctor may then order a fibrinogen level ( a
clotting protein that is another marker of inflammation) and serum
protein electrophoresis to determine which one of them ( or both)
causing the elevated ESR.
In a pediatric setting, ESR test is used in diagnosis and monitoring
of the children with rheumatoid arthritis or Kawasaki’s disease.

Some medications such as dextran, methyldopa, oral contraceptives,

penicillamine procainamide, and vitamin A can cause an increase in
ESR On another hand, aspirin, cortisone, and quinine may decrease it.

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 Principle of ESR
 When anticoagulated blood is allowed to stand in a narrow vertical glass tube,
undisturbed for a period of time, the RBCs – under the influence of gravity- settle
out from the plasma. The rate at which they settle is measured as the number of
millimeters of clear plasma present at the top of the column after one
hour(mm/hr). This mechanism involves three stages:
Stage of aggregation
It is the stage of rouleaux formation/aggregation. It occurs in the first 10-15 min.

Stage of sedimentation
It is the stage of actual RBCs sedimentation, it occurs at constant rate. This occurs
in 30-40 minutes out of 1hr.

Stage of packing
This is the final stage and is also known as stationary phase. In this stage, there is a
slower rate of falling during which packing of sedimenting RBCs in column
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occurs due to overcrowding. It occurs in final 10 minutes in 1 hour.
 Methods Of ESR Determenation
There are two main methods to determine ESR :
• Widely used method for ESR estimation. It
Westergren Method is the method that we are going to use in
today lab.

• Also used for ESR determination. Wintrobe

Wintrobe Method tube is smaller than Westergren tube.

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 Material and Instruments of
Westergren Method
• Westergren pipette (30 cm in length and 2 mm in diameter). It is graduated
and open at both ends. The lower 20 cm are marked with 0 at the top and
200 at the bottom.
• Westergren pipette rack equipped with levelling screws.
• 3.8 % Sodium Citrate as anticoagulant in a ratio of 1:4 with blood.
• Plain test tubes 13× 100 mm.
• Syringe for withdrawal blood from the vein of the subject/patient.

ESR Pipette and Rack

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 Procedure
• Put 0.4 cc of Sodium Citrate in a plain test tube.
• Withdraw 2 cc of blood from the patient vein using a syringe.
• Immediately, add 1.6 cc of blood from the syringe in the plain tube
and shake the tube for 2 min to ensure a good mixing of blood with
Sodium Citrate.
• Fill the Westergren pipette exactly to 0 mark, make sure that there
are no air bubbles at all in the blood.
• Place the pipette vertically on the rack and leave it undisturbed for
60 min. Avoid any vibration to the tube and do not expose it to a
direct sunlight.
• At the end of the 60 min, read the number of millimeter the RBCs
have fallen (i.e the height of clear plasma above the upper limit of
the column of the sedimentating cells).
• Read the results in mm/hr.
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 Westergren Method Versus Wintrobe Method
Note: Wintrobe method has the same procedure as
Westergren method except that at the end of the one hour
the tube is centrifuged at 2000-3000 rpm to complete the
separation of RBCs which enables us to get the PCV value .

Advantages Disadvantages
 Westergren method is more In Westergren method:
reliable than Wintrobe  More blood is required.
method and gives accurate  Difficult to fill blood in the tube.
result.  PCV cannot be done.
 Mouth pipetting can be
hazardous.

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 Clinical Implications
ESR increases in :
 Anemia
- Anemia increases ESR because the change in erythrocyte-plasma ratio
favors rouleaux formation.
- Rouleaux tends to decrease the surface area and accelerate ESR.
 Increase the level of fibrinogen
 Increase cholesterol level
 Rheumatoid arthritis
 Acute and chronic infections
 Carcinoma
 Old age and Pregnancy (physiological not pathological)
 Tuberculosis
 Tissue destruction and other disease
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 Clinical Implications

ESR decreases in :

Polycythemia
RBCs abnormalities: abnormal or
ESR irregular shape of RBC lower ESR.
decreases Spherocytosis
in :
Congestive heart failure
Increase albumin level in the blood
ALLPPT.com _ Free Powerpoint Templates, Diagrams and Charts

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 Technical Errors
Some Important Notes

• Because ESR determination is frequently performed in

office laboratories , careful attention to some technical
factors that may produce erroneous values is important.

• A tilted ESR tube, an increase in the temperature, and

sample dilution can cause an artefactual elevation.

• Inadequate anticoagulants with a clotting in the blood

sample ( consequently will consume fibrinogen), short
ESR tube, and vibration during the test may artifictually
lower the ESR.

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 Extreme Elevation of ESR
• An extreme elevation in ESR (defined as greater than 100 mm/hr)is
associated with a low false positive rate for serious underlying diseases. The
conditions found in this situation have varied in individual populations
depending on the patient age and inpatient versus outpatient status. In most
series, infection has been the leading cause of an extremely elevated value
followed by collagen vascular disease and metastatic malignant tumors. Renal
disease has also been a notable etiological factor .
• Because most of these conditions are clinically apparent, any tests performed
should be clinically driven. For instance, if symptoms of infection are present,
the appropriate cultures, including urine and blood, and skin testing for
tuberculosis should be obtained. An exhaustive search for an occult malignancy
should not be undertaken because if cancer is present, it is almost always
metastatic.
• No obvious cause is apparent in less than 2% of the patients with markedly
elevated ESR. In such patients, the history and physical examination coupled
with readily available tests will usually establish the etiology.
• Because a notable number of patients with ESR more than 100 mm/hr have
myeloma or some other type of dysproteinemia, urine and protein
electrophoretic studies should be included in the testing.
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