DR.

RAJENDRA PRASAD GOVERNMENT MEDICAL

COLLEGE & HOSPITAL, KANGRA (HP)
DEPARTMENT OF PATHOLOGY
‘SEMINAR’

ERYTHROCYTE
SEDIMENTATION
RATE
 OVERVIEW
01 Introduction

02 Principle of ESR

03 Stages of ESR

04 Factors Affecting ESR

05 Methods for Estimation of ESR

06 Clinical Significance of ESR

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 01
Introduction
• Erythrocyte sedimentation rate (ESR) is a nonspecific test for inflammation in the body.

• Estimation of ESR is a widely used test in clinical practice as it is easy to perform, widely
available and inexpensive.

• It is also used as a monitoring tool for response to treatment in conditions in which it is

raised like tuberculosis, rheumatic fever, rhematoid arthritis, multiple myeloma and other
autoimmune diseases.

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 02
PRINCIPLE
• The principle for ESR testing is based on the differences in
densities of plasma proteins and RBCs.

• Consist of allowing a specific amount of blood to sit in a

vertical position for a period of time(usually one hour).

• The distance, in millimeters, that the red cells fall during this
time period is the Erythrocyte Sedimentation Rate and is
reported in mm at one hour.

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 STAGES OF ESR
• ROULEAUX FORMATION: This occurs in first 15 minutes and minimum sedimentation occurs.

• FORMATION OF THREADS: This occurs in next 15 minutes because of globulin and fibrinogen.

• RAPID FALL: Protein network along with the red cell mass falls in next 15 minutes.

• PACKING PHASE: Packing of RBCs occurs during the last 15 minutes.

 STAGES OF ESR
1.Rouleaux formation 2.Formation of fine threads 3.Packing phase and rapid fall.

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 FACTORS AFFECTING ESR
1. Rate of rouleaux formation: Sedimentation of red cells is greatly influenced by the extent to which the
red cells form rouleaux. More is the formation of rouleaux, higher will be the ESR.

2.Ratio of red cells to plasma (hematocrit) : Hematocrit also influences ESR. In anemic patients, the
number of red cells is less and the proportion of plasma is more. The higher proportion of plasma
increases rouleaux formation and hence increases ESR.

3. Type of red cells: Sickle cells and spherocytes do not form rouleaux and hence ESR is decreased in
Hereditary spherocytosis and sickle cell anemia.

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 FACTORS AFFECTING ESR
4. Plasma viscosity: ESR increases as the plasma viscosity increases. Viscosity is dependent on the
concentration of fibrinogen and other plasma proteins.

5. Length of the tube: Longer the tube, longer will be the duration of the second phase and higher will be
the ESR.

6. Verticality of the tube: If the tube is not vertical, sedimentation occurs more quickly due to streaming of
blood down the wall of the sloped tube. Deviations as small as 3% from absolute vertical can increase the
ESR by 30%.

7. Temperature: Sedimentation is accelerated as the temperature increases.ESR is hence always

measured at room temperature(18- 25°C).

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 METHODS FOR ESTIMATION OF ESR

The four methods commonly employed are:

1. Westergren’s method
2. Wintrobe’s method
3. MicroESR method
4. Automated method

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WESTERGREN’S
METHOD Instruments used in this method are as follows:

1. Westergren’s pipette.

30cm in length.

2.5cm internal diameter.

Marking on the tube is 0 to 200mm.

Should be clean and dry.

2. Westergren’s rack.

3. Leveling plate for holding the westergren rack.

4. Anticoagulant used 3.8% trisodiumcitrate dihydrate

solution (1:4).
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 WESTERGREN’S METHOD
SPECIMEN
• Venous blood collected in 3.8% Trisodium citrate pentahydrate solution (1 in 4 parts of blood).

• Mix the blood and anticoagulant thoroughly.

• Test should be carried out within four hours of blood collection if the specimen is kept at room
temperature.

• There should be no clots and air bubbles in the blood.

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 WESTERGREN’S METHOD
PROCEDURE
• Collect 2 ml of blood in 0.5 ml of 3.8% Trisodium citrate pentahydrate
solution (1 in 4 parts of blood).

• Mix the two and withdraw blood by rubber teat attached on top of
Wetergren’s pipette up to 0 mark (at top).

• Place the pipette on the rubber cork of Westergren’s stand and make it
vertical using the adjustable leveling screws and detach the rubber teat.

• Measure the height of the plasma column after 1 hour. This gives the
ESR in mm in the 1st hour.

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WESTERGREN’S METHOD
NORMAL RANGE

Men 0 to 10mm 1st hour

Women 0 to 20mm 1st hour

ADVANTAGES

This is a more sensitive and accurate method as compared to Wint robe’s

method because the column is longer, i.e. 200mm

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WINTROBE’S
METHOD
Instruments used for this method are as follows:

1. Wintrobe’s pipette

• 110mm long, narrow, thick-walled tube with an internal bore of 3mm. Graduated from 0
to 10 cm with graduation both in ascending and descending order on both sides of the
tube.

• The scale with markings from 0 to 10 from above to downwards is used in ESR
determination and from below to upward is used for hematocrit (PCV) determination.

2. Wint robe’s stand

3. Anticoagulant used is EDTA.

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WINTROBE’S METHOD
PROCEDURE

• Collect 2ml blood in an EDTA vial.

• Fill the pasteur pipette having a long stem.

• The tip of the P. pipette is taken to the bottom of the W. tube and
blood is slowly filled into the tube; the pipette is slowly withdrawn
and blood is filled up to top mark of 0/10.

• Keep the tube in a vertical position for 1 hour in the Wintrobe

tube stand and note the fall in red cells from the top mark of 0.

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 WINTROBE’S METHOD
NORMAL RANGES

Adult males 0 to 7 mm 1st hour

Adult females 0 to 14 mm 1st hour

ADVANTAGES

• Simple method as small amount of blood is required.

• After measuring ESR, the same tube can be centrifuged to

determine PCV.

• Smears of the buffy coat can be made in cases of

• Leucopenia, subleukemic/aleukemic leukaemia, and for LE cell test.

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 SOURCES OF ERROR
• Improper ratio of blood and anticoagulant.
• Hemolysed sample.
• Clotted blood.
• Presence of air bubbles.
• Error due to sunlight, vibration, small bore size, dirty and wet tube.
• Delay in performing the test.
• Heparin alters red cell membrane potential and therefore should never be used for ESR.

PRECAUTIONS
• The tube should not be inclined, should be vertical.
• Ratio of anticoagulant to blood should be 1:4.
• There should not be any clot in the blood sample

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 ESR MICROMETHOD
This is an automated method with an internal mixing and reading function and the equipment has got an
infrared sensor which avoids interference caused by the presence of lipids and bilirubin in the blood
sample.

SPECIMEN:

The test is performed using 1ml of blood and evacuated tubes prefilled with sodium citrate solution are
used.

ADVANTAGES:

1. The results are precise and correlated with those obtained by western method.

2. Reading time is 20 minutes in comparison to 1 hour by the conventional method.

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 AUTOMATED ESR METHOD
Automated equipment is now available to record the ESR. EDTA tube with blood is placed in the equipment.
Through the analog sensors, the instrument automatically determines the sedimentation level of
erythrocytes.

ADVANTAGES:

1. Recently, equipment that recorded ESR in less than 1 minute. are being made available.

2. Automated equipment are fast, walk-away system and provides accurate results.

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 CLINICAL SIGNIFICANCE
OF ESR
Acute phase reactants like fibrinogen, CRP, alpha-1- Antitrypsin, and ceruloplasmin are
elevated in acute diseases resulting in an increase of ESR. A Large number of chronic
diseases, degenerative diseases, and malignancies are associated with alterations in
plasma proteins and fibrinogen resulting in acceleration of ESR.

DECREASED ESR

Higher hematocrit in polycythemia reduces the ESR.

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 CLINICAL SIGNIFICANCE
OF ESR
INCREASED ESR

Increased ESR is indicative of the activity of the disease process. Return to normal of a previously
elevated ESR suggests abating inflammatory disease process.

Since globulins and fibrinogen affect ESR values abnormal globulins in multiple myeloma,
Waldenstrom, macroglobulinemia increase ESR while hypofibrino- genemia in liver diseases reduces
ESR. Antibodies bound to the surface of red cells in Autoimmune hemolytic anemias elevate the ESR
due to rapid rouleaux formation

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 ALTERATIONS IN ESR
INCREASED ESR DECREASED ESR

1. Infective diseases – tuberculosis 1. Polycythemia rubra vera

2. Chronic inflammatory diseases 2. Sickle cell disease

• rheumatic fever
• rhematoid arthritis 3. Hypofibrinogenemia in liver disease
• SLE, temporal arteritis
• ankylosing spondylitis

3. Hypergammaglobulinemias
• multiple myeloma
• Waldenstrom macroglobulinemias
• autoimmune hemolytic anemia

4. Hodgkin disease.

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 THANK YOU

PRESENTED BY:

JAGRITI SINGH

B.Sc MEDICAL LABORATORY TECHNOLOGY (1st

YEAR)

ROLL NO.- 03