ERYTHROCYTE SEDIMENTATION RATE

PRINCIPLE:
When anticoagulated blood is allowed to stand undisturbed, the
red blood cells will normally settle out to the bottom of the tube.
This principle is the basis for the erythrocyte sedimentation rate
(ESR). By definition, the ESR is the distance in millimeters that
the red cells fall (in millimeters) per unit of time, which is
usually 1 hour. Various factors will affect the ESR, such as the
size and shape of the red cells, plasma fibrinogen, and globulin
levels, as well as mechanical and technical factors.
The ESR is directly proportional to the red cell mass and
inversely proportional to the plasma viscosity.
In normal whole
blood red blood cells do not form rouleaux; the red cell mass is
small and therefore the ESR is decreased (cells settle out slowly).
In abnormal conditions when red cells can form rouleaux, the red
cells mass is greater, thus increasing the ESR (cells settle out
faster).
Historically, there have been two methods for the erythrocyte
sedimentation rate - the Wintrobe method and the Westergren method.
Several newer methods, including an automated method, and
modifications have been developed in recent years but have not been
well-accepted.
One newer modification of the ESR is capable of
using smaller sample sizes, however, it has not been accepted as a
standard procedure yet.
DISCUSSION:
The ESR is a non-specific test procedure, but is useful as a
screening test. It is of benefit in differentiating among certain
disease processes that have similar symptomatology (see Table
below) and in monitoring the course of an existing condition. It's
primary use is in detecting inflammatory conditions. Inflammatory
processes cause an increase in a number of proteins found in the
blood. The increase in these proteins, such as fibrinogen, result
in increased plasma viscosity and a resulting increased or
accelerated erythrocyte sedimentation rate.
INTERPRETATION AND COMMENTS:
The ESR is affected by a number of mechanical and technical
factors.
1.

2.

It is absolutely essential that the ESR be on a level surface

and that the table or area in which the tube is placed is free
of vibration, direct sunlight (or other sources of heat), or
drafts. A tilt of as little as 3o from vertical will affect
the ESR.
The sample must be collected in an appropriate anticoagulant
and in the proper proportion with the anticoagulant. EDTA

3.
4.
5.
6.

7.
8.

9.
10.
11.

12.

is the anticoagulant of choice, but sodium citrate (blue-top

tube) is also acceptable. Other anticoagulants can cause RBC
shrinkage and as a result a falsely elevated ESR.
It is important that the blood and anticoagulant be in
the proper proportion since excessive anticoagulant can also
cause shrinkage of the red cells.
The blood should be mixed thoroughly.
The ESR should be set up within 1 hour of collection of the
sample. However, some authors agree that the sample can be
held for up to 6 hours if the sample is refrigerated.
When the ESR tube is filled it must not contain any bubbles.
At the end of 60 minutes, the fall of the red cells is read as
the level of the top of the red cell column (see attached
diagrams) in millimeters. If using a tube, such as the Wintrobe tube that has two scales, use the scale that starts at
0 at the top. The ESR is read as the rate of fall of the
red cells in millimeters per hour (mm/hr).
If the line of demarcation between the red cells and the
plasma is hazy, take the level where the full density of
red cells is first apparent.
Because the red cell shape affects the rate of fall of the
cells, it should be apparent that sickle cells and spherocytes
will result in a potential falsely decreased ESR. Other
conditions that result in poikilocytosis (variation in the
shape of the red cells) will produce similar results.
There is considerable dispute about the effect of severe
anemia on the ESR. Some laboratories correct the ESR in cases
of severe anemia.
Note that the normal ranges vary slightly with age, sex, and
method.
Some Westergren tubes (almost all of the newer types) are
self-zeroing. They have a cotton plug in the "zero" end.
If the blood is pulled up to and into the cotton plug, you
do not have to take any further action to zero the tube, since
the blood caught in the cotton plug will not participate in
the fall of the cells. The cotton plug will also prevent
leakage of blood from the open end of the tube.
COMPARISON OF THE SEDIMENTATION RATE METHODS:
The Westergren method is the most sensitive of the sedimentation rate methods because of the longer tube, but it requires more blood.
The Wintrobe method requires a smaller amount of blood and
involves no dilution. In addition, once the ESR has been
read, the Wintrobe tube can be centrifuged to obtain a macrohematocrit, and blood films can be made from the buffy coat.
However, because of the shorter column of blood, the Wintrobe
methods is not as sensitive as the Westergren.

TABLE OF SIMILAR DISEASE PROCESSES AND THE ESR RESULTS:

DISORDERS
ERYTHROCYTE SEDIMENTATION RATE
_____________________________________________________
Viral infection
Normal
vs.
Bacterial infection

-----------------------------------------------------Early acute appendicitis

Normal
vs.
Acute pelvic inflammatory

disease or ruptured
ectopic pregnancy
-----------------------------------------------------Established myocardial

infarction
vs.
Angina pectoris
Normal
-----------------------------------------------------Rheumatic fever, rheumatoid

arthritis & pyogenic arthritis

vs.
Osteoarthritis
Normal
------------------------------------------------------

MALES
FEMALES
CHILDREN
NORMAL RANGES:
_________________________________________________________________
WINTROBE
WESTERGREN

0-7 mm/hr
<50 yrs
>50 yrs

0-10 mm/hr
0-20 mm/hr

0-15 mm/hr
0-20 mm/hr
0-30 mm/hr

4-14 yrs

0-20mm/hr