ESR

1. Dr.Asif Iqbal
2nd year P.G

2.  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 (

3.  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.

4. 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.

5.  The initial lag phase (10m)
 The phase of rapid RBC falling(40m)
 The packing phase (10m)

8.  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 .

10.  Adult females 0-20 mm/h
 Adult males 0-15 mm/hr
 Children(<10) 0-10 mm/hr

11. 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

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

13.  -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

14. 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 .

15.  ESR of more than 100 mm/hr is
strongly associated with serious
underlying disorders like connective
tissue disease, infections and
malignancies

16.  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.

17.  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.

18.  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.

19.  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.

20.  Multiple myeloma
 Connective tissue
 Autoimmune diseases
 Tuberculosis
 Malignancies
 Severe anemia

21.  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 .

22.  Polycythemia
 Severe Leukocytosis
 Sickle cell disease.
 Hereditary spherocytosis
 Congestive cardiac failure
 Corticosteroid use

23.  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 .

24.  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

25.  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 .

26.  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 .

27.  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.

28. Thank you