Erythrocyte

sedimentation rate
• Erythrocyte sedimentation rate (ESR) is a non-specific test for
inflammation.
• It is easy to perform, widely available,
• 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).

• Basics:
• The ESR test is performed in the laboratory by placing
anticoagulated blood in an upright tube (Westergren's most
often).
• At the end of one hour, the rate of the RBC sedimentation
is measured.
 Factors affecting the ESR
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.

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.
C- Technical factors

• Perpendicularity of sedimentation tube, Vertical can increase

the result.

• Temperature (RT 18-25 C) higher temperature cause false

high results due to reduction in plasma viscosity

• Vibration can reduce the ESR.

 Sedimentation Phases

• 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 .
Reference Range

• Adult females 0-20 mm/h

• Adult males 0-15 mm/hr

• Children (<10) 0-10 mm/hr

Mechanism
• 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
Procedure
• Patient must fasting at least 4 hours before testing.
• The blood sample must be mixed with anticoagulant
agent in this test.
• Put 0.4 ml sodium citrate + 1.6 ml blood . OR put
0.2 ml sodium citrate + 0.8 ml blood .
• Mix gently with out shaking then put in the graded
tube and leave it stand vertically on the stand for 1
hour.
• 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
• ESR of more than 100 mm/hr is strongly
associated with serious underlying disorders
like connective tissue disease, infections and
malignancies.

• ESR is helpful in diagnosing two specific

inflammatory diseases ,temporal arteritis and
polymyalgia rheumatica.
Some conditions with very high ESR
>100 mm/hr
• Multiple myeloma.
• Connective tissue disorders - RA
• Tuberculosis.
• Malignancies.
• Severe anemia.
Some conditions with low ESR :
• Polycythemia
• Sickle cell disease (anemia(
• Hereditary spherocytosis
• Corticosteroid use
• Hypofibrinogenemia

• Note that sickle cell anemia and spherocytosis have low ESR
unlike other anemia's.
• This is due to reduced rouleaux formation owing to the
abnormally shaped RBCs in this condition.
Important
• 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).