ESR = ESR = ERYTHROCYTE ERYTHROCYTE

SEDIMENTATION SEDIMENTATION RATERATE

Dr. MOHAMMED Dr. MOHAMMED CHYAD CHYAD

AL-NOAEMIAL-NOAEMI

What is the normal What is the normal sedimentation rate?sedimentation rate?

The normal sedimentation rate The normal sedimentation rate (Westergren method):(Westergren method): for males is 0-15 millimeters per hour, for males is 0-15 millimeters per hour, females is 0-20 millimeters per hour.females is 0-20 millimeters per hour. The sedimentation rate can be slightly The sedimentation rate can be slightly more elevated in the elderly.more elevated in the elderly.It is also increase in pregnancy and It is also increase in pregnancy and menstrual period.menstrual period.

The clinical usefulness of The clinical usefulness of ESR ESR

Its increase indicates Its increase indicates infectioninfection, or , or inflammationinflammation, or , or malignancymalignancy, or , or anemiaanemia. . However, it rarely leads directly to a specific However, it rarely leads directly to a specific diagnosis.(i.e. a diagnosis.(i.e. a nonspecific testnonspecific test))

It is considered as an index for assessment of It is considered as an index for assessment of severityseverity of inflammatory conditions. ESR is of inflammatory conditions. ESR is increased according to the severity of the increased according to the severity of the disease.disease.

It is used to It is used to monitor the response to monitor the response to therapy therapy in certain inflammatory diseases.in certain inflammatory diseases.

It is done if there is a suspicion of disease, the It is done if there is a suspicion of disease, the ESR may have some value as a "ESR may have some value as a "sickness sickness indexindex.“.“

Changes in ESRChanges in ESR

The ESR is The ESR is increasedincreased by any cause or focus by any cause or focus of of inflammationinflammation (acute or chronic). (acute or chronic).

However, it is useful in detecting and However, it is useful in detecting and monitoring monitoring tuberculosistuberculosis, certain forms of , certain forms of arthritis, arthritis, autoimmuneautoimmune disorders, and disorders, and diseases that cause vague symptoms.diseases that cause vague symptoms.

Diseases in general are either mild, Diseases in general are either mild, moderate or sever. Therefore, ESR is moderate or sever. Therefore, ESR is increased according to the severity of the increased according to the severity of the disease.disease.

The ESR is The ESR is decreaseddecreased in in sickle cell anemia, , polycythemia, and , and congestive heart failure..

The erythrocyte The erythrocyte sedimentation rate (ESR)sedimentation rate (ESR) Is also called a Is also called a sedimentation ratesedimentation rate, , sed sed

raterate, is the rate at which , is the rate at which red blood cells precipitate in a period of 1 hour. precipitate in a period of 1 hour.

It is a common It is a common haematologyhaematology test which is test which is a a non-specificnon-specific measure of measure of inflammationinflammation. .

To perform the test, anticoagulated To perform the test, anticoagulated bloodblood is placed in an upright tube, known as a is placed in an upright tube, known as a Westergren tube and the rate at which the Westergren tube and the rate at which the RBCRBC fall is measured and reported in fall is measured and reported in mm/h.mm/h.

Method (Westergren Method (Westergren Tube)Tube)

Blood is obtained by clean venepuncture, and Blood is obtained by clean venepuncture, and thoroughly mixed in a proportion of 4 volumes of blood thoroughly mixed in a proportion of 4 volumes of blood (as 2ml) to 1 volume of filtered solution of sodium (as 2ml) to 1 volume of filtered solution of sodium citrate (0.5ml).citrate (0.5ml).

Or 2ml of EDTA anti-coagulated blood + 0.5ml of Or 2ml of EDTA anti-coagulated blood + 0.5ml of diluting fluid as normal saline (0.9%NaCl). Blood is diluting fluid as normal saline (0.9%NaCl). Blood is mixed thoroughly with the anticoagulant by gentle mixed thoroughly with the anticoagulant by gentle repeated inversion. A clean dry Westergren tube is repeated inversion. A clean dry Westergren tube is filled and adjusted to the 0 mark. The tube is then filled and adjusted to the 0 mark. The tube is then placed in a strictly vertical position under room placed in a strictly vertical position under room temperature (18-25C). After one hour the distance temperature (18-25C). After one hour the distance from zero to the top of the column of sedimenting red from zero to the top of the column of sedimenting red cells is read in mm and recorded as ESR value. The cells is read in mm and recorded as ESR value. The result is expressed as:result is expressed as:

ESR= ? mm/hour.ESR= ? mm/hour.

ESR -TubesESR -Tubes

Wintrobe MethodWintrobe Method

This picture shows a rack holding This picture shows a rack holding Wintrobe tubes, in which Wintrobe tubes, in which anticoagulated whole blood has just anticoagulated whole blood has just been added.been added.

(Time: 0)(Time: 0)

Wintrobe MethodWintrobe Method

Red blood cells have settled, leaving Red blood cells have settled, leaving plasma at the top of the tube. plasma at the top of the tube. Reading: 18 mm/hourReading: 18 mm/hour

(Time: one hour)(Time: one hour)

The Wintrobe The Wintrobe sedimentation racksedimentation rack

Method (WintrobeTube)Method (WintrobeTube) By putting Anticoagulated blood directly into By putting Anticoagulated blood directly into

the wintrobe tube (without dilution).the wintrobe tube (without dilution). It is used for demonstration.It is used for demonstration. The normal values will be slightly less than The normal values will be slightly less than

westergren method. westergren method.

[This method is less accurate than the [This method is less accurate than the westergren method.Br Med J. 1951 December westergren method.Br Med J. 1951 December 22; 2(4746): 1496–1497.Westergren and 22; 2(4746): 1496–1497.Westergren and Wintrobe Methods of Estimating E.S.R. Wintrobe Methods of Estimating E.S.R. Compared.David Gilmour and A. J. Sykes].Compared.David Gilmour and A. J. Sykes].

Wintrobe method:Wintrobe method: The Wintrobe method is performed similarly The Wintrobe method is performed similarly

except that the Wintrobe tube is smaller in except that the Wintrobe tube is smaller in diameter than the Westergren tube and only diameter than the Westergren tube and only 100 mm long. EDTA anticoagulated blood 100 mm long. EDTA anticoagulated blood without extra diluent is drawn into the tube, without extra diluent is drawn into the tube, and the rate of fall of red blood cells is and the rate of fall of red blood cells is measured in millimeters after 1 hour. The measured in millimeters after 1 hour. The shorter column makes this method shorter column makes this method less less sensitive sensitive than the Westergren method than the Westergren method because the maximal possible abnormal because the maximal possible abnormal value is lower. However, this method is more value is lower. However, this method is more practical for practical for demonstrationdemonstration purposes. purposes.

http://www.medicine.mcgill.ca/physio/vlab/bloodlab/esr.htmhttp://www.medicine.mcgill.ca/physio/vlab/bloodlab/esr.htm

Mechanism of ESR Mechanism of ESR FormationFormation

The ESR is governed by the balance between pro-The ESR is governed by the balance between pro-sedimentation factors, mainly sedimentation factors, mainly fibrinogenfibrinogen, and , and those factors resisting sedimentation, namely the those factors resisting sedimentation, namely the negative charge of the erythrocytes. When an negative charge of the erythrocytes. When an inflammatory process is present, the high inflammatory process is present, the high proportion of fibrinogen in the blood causes red proportion of fibrinogen in the blood causes red blood cells to stick to each other. The red cells blood cells to stick to each other. The red cells form stacks called 'form stacks called 'rouleauxrouleaux' which settle faster. ' which settle faster. Rouleaux formation can also occur in association Rouleaux formation can also occur in association with some lymphoproliferative disorders in which with some lymphoproliferative disorders in which one or more one or more immunoglobulinsimmunoglobulins are secreted in high are secreted in high amounts. amounts.

http://www.medicine.mcgill.ca/physio/vlab/bloodlab/http://www.medicine.mcgill.ca/physio/vlab/bloodlab/esr.htmesr.htm

Erythrocytes aggregate in a special way, forming rouleaux. Erythrocytes aggregate in a special way, forming rouleaux. Rouleaux are stacks of erythrocytes which form because of the Rouleaux are stacks of erythrocytes which form because of the unique discoid shape of the cells. The flat surface of the discoid unique discoid shape of the cells. The flat surface of the discoid RBCs give them a large surface area to make contact and stick to RBCs give them a large surface area to make contact and stick to each other; thus, forming a rouleaux. each other; thus, forming a rouleaux.

Normal distributed RBCNormal distributed RBC

Precipitated RBC by Precipitated RBC by

rouleaux formation in ESRrouleaux formation in ESR

tubetube

Rouleaux FormationRouleaux Formation The RBC's here have stacked together in long chains. The RBC's here have stacked together in long chains.

This is known as "rouleaux formation" and it happens This is known as "rouleaux formation" and it happens with increased serum proteins, particularly with increased serum proteins, particularly fibrinogenfibrinogen and and globulinsglobulins. Such long chains of RBC's sediment . Such long chains of RBC's sediment more readily. This is the mechanism for the more readily. This is the mechanism for the sedimentation rate, which increases non-specifically sedimentation rate, which increases non-specifically with inflammation and increased "acute phase" serum with inflammation and increased "acute phase" serum proteins.proteins.

ESR at zero time ESR after ESR at zero time ESR after one hourone hour

ESR (mm/hr) reference ranges ESR (mm/hr) reference ranges from a large 1996 study from a large 1996 study

AgeAge (years) (years) 2020 5555

9090 MenMen 10 15 19 10 15 19 Women Women 15 21 2315 21 23

Normal values of ESR have been quoted as 1 to Normal values of ESR have been quoted as 1 to 2 mm/hr at birth, rising to 4 mm/hr 8 days after 2 mm/hr at birth, rising to 4 mm/hr 8 days after delivery, and then to 17 mm/hr by day 14.delivery, and then to 17 mm/hr by day 14.

Normal ValuesNormal Values(mm/hr. = millimeters (mm/hr. = millimeters

per hour)per hour) The widely used rule for calculating The widely used rule for calculating

normal maximum ESR values in normal maximum ESR values in adults (98% confidence limit) is adults (98% confidence limit) is given by a formula devised in 1983given by a formula devised in 1983

MaterialsMaterials

Anticoagulant-Diluent SolutionAnticoagulant-Diluent Solution

Trisodium citrate dehydrate (31.3 gram/L -DW) Trisodium citrate dehydrate (31.3 gram/L -DW)

The solution is filtered through a sterile The solution is filtered through a sterile

membrane, maximum pore diameter 0.22 mm, membrane, maximum pore diameter 0.22 mm,

into a sterile container. It must be discarded if into a sterile container. It must be discarded if turbid.turbid.

Westergren tube Westergren tube is graduated from 0-200mm.is graduated from 0-200mm. BloodBlood sample. sample.

Is there anything else we should know?

• 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.

• If the ESR is elevated, it is typically a result of globulins or fibrinogens. Your doctor may then order a fibrinogen level (a clotting protein that is another marker of inflammation) and a serum protein electrophoresis to determine which of these (or both) is causing the elevated ESR.

Relation to C-reactive Relation to C-reactive proteinprotein

C-reactive protein is an acute phase protein C-reactive protein is an acute phase protein that is produced by the liver during an that is produced by the liver during an inflammatory reaction. Since C-reactive inflammatory reaction. Since C-reactive protein levels in the blood rise more quickly protein levels in the blood rise more quickly after the inflammatory or infective process after the inflammatory or infective process begins, ESR is often replaced with C-reactive begins, ESR is often replaced with C-reactive protein measurement. protein measurement. There are specific There are specific drawbacks, however, as they were found to be drawbacks, however, as they were found to be independently associated with a diagnosis of acute independently associated with a diagnosis of acute maxillary sinusitis so that the combination of the maxillary sinusitis so that the combination of the two measurements improved diagnostic sensitivity two measurements improved diagnostic sensitivity and specificity.and specificity.

REFERENCES

1. Practical Physiology. Mohammed Chyad Al-noaemi2. J Clin Pathol. 1973 April; 26(4): 301–302.•PMCID: PMC4777083. The most satisfactory method of performing the test was introduced by Westergren in 1921.[Saadeh C. The erythrocyte sedimentation rate: old and new clinical applications. South Med J. 1998;3:220–5.].4.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC477708/?page=1