Erythrocyte Sedimentation Rate (ESR)

Erythrocyte Sedimentation Rate (ESR)
Erythrocyte Sedimentation Rate
When anticoagulated blood is allowed to stand undisturbed in a vertical tube, the red cells tend to fall to the bottom forming two layers – the lower red cell layer and the upper plasma layer.

This occurs in three stages:
1.Stage of aggregation: The red cells form rouleaux. This is the most important stage and factors which affect this stage markedly alter sedimentation rate
2.Stage of sedimentation: The larger the aggregates formed in stage 1, the faster the rate of fall
3.Stage of packing: The individual cells and aggregates slow down due to crowding
Methods of measuring ESR
There are two common methods of measuring ESR
Westergren’s method is more sensitive and accurate
Wintrobe’s method uses smaller volumes of blood and the same tube can be centrifuged later for PCV and buffy coat.
Wintrobe’s Method
Westergren’s Method
1. Blood is drawn by venepuncture and then collected in a dry bulb containing Wintrobe’s oxalate mixture.
1. 2 ml of blood is added to a tube containing 0.3 ml sodium citrate solution.
2. After mixing with oxalate, blood is transferred to the Wintrobe’s tube with a Pasteur pipette up to mark ‘0.
2. Blood is drawn into the Westergren’s tube up to ‘0’ mark.
3. The tube is placed vertically in its stand and the time is noted,
3. The tube is placed vertically on a special stand in which a spring clip on the top firmly holds the tube against the rubber at the lower end. 
4. At the end of 1 hour, the reading corresponding to the top of the red cell layer (in mm) is the ESR.
4. At the end of 1 hour, the reading corresponding to the top of the red cell layer is noted in mm. This measurement is ESR.
Normal ESR values
Normal ESR
using Wintrobe’s Method
using Westergren’s Method
0 – 7 mm/hour
0 – 10 mm/hour
0 – 14 mm/hour
0 – 20 mm/hour
Causes of Increased ESR
Causes of Increased ESR
Physiological: Pregnancy, menstruation, old age, females
Infectious diseases: TB (maximum in miliary TB)
Inflammatory conditions, cell destruction, toxemia: Rheumatic fever, rheumatoid arthritis, SLE, ankylosing spondylitis, nephrosis.
Myocardial infarction
Post-operative states
Hypergammaglobulinemia: AIHA, multiple myelomas, Waldenstrom’s macroglobulinemia
Causes of Decreased ESR
Causes of Decreased ESR
Physiological: Newborns due to polycythemia, males
Congenital spherocytosis
Sickle cell disease
Allergic states
Significance of ESR
Significance of ESR
Changes in ESR indicates presence and intensity of an inflammatory process, they are not diagnostic of any specific condition.
ESR has prognostic value. Elevated ESR (as in rheumatic fever or tuberculosis), if returns to normal suggest improvement in the clinical course.
Extreme elevation of ESR is seen in malignancies, hematological diseases (e.g. myeloma), renal diseases (e.g. azotemia), collagen diseases (e.g., RA, SLE, polymyalgia rheumatica), severe infections (e.g. osteomyelitis, subacute bacterial endocarditis), cirrhosis, etc.
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