The document discusses the erythrocyte sedimentation rate (ESR), a common medical test used to detect inflammation. It describes how ESR is measured by allowing anticoagulated blood to stand vertically and measuring the rate at which red blood cells sediment. Normal ESR rates vary by age and sex. Factors like plasma proteins, number of red blood cells, temperature, and anticoagulants can influence ESR. The document also outlines different methods for measuring ESR, including the Wintrobe and Westergren methods, and clinical situations where ESR may be evaluated.

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2. ERYTHROCYTE SEDIMENTATION
RATE
COMMONLY USED NON SPECIFIC TEST IN ROUTINE
CLINICAL PRACTICE
 OTHER HIGH SENSITIVITY INFLAMMATORY MARKERS
 ( EG. C-REACTIVE PROTEIN) ARE PRESENTLY USED TO
DETECT OR MONITOR DISEASE ( EG.
CARDIOVASCULAR DISEASE AND METABOLIC
SYNDROME )
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3. ERYTHROCYTE SEDIMENTAION RATE
PRINCIPLE
WHEN ANTICOAGULATED BLOOD IS PLACED IN A
VERTICAL TUBE AND IS ALLOWED TO STAND,RBCS
SETTLE TOWARDS THE BOTTOM OF THE TUBE
SPEED OF SEDIMENTATION OF RED CELLS IN
PLASMA OVER A PERIOD OF 1 HOUR IS
MEASURED BY THE LENGTH OF THE SEDIMENT
RBC COLUMN AND IS EXPRESSED IN MILLIMETERS
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4. ERYTHROCYTE SEDIMENTAION
RATE
RBCS HAVE NET NEGATIVE CHARGE ON THEIR
SURFACE AND TEND TO REPEL EACH OTHER .THE
REPULSIVE FORCES ARE PARTIALLY OR TOTALLY
COUNTERACTED IF THERE IS AN INCREASE IN THE
POSITIVELY CHARGED PLASMA PROTEINS
THIS PROCESS IS CALLED “SEDIMENTATION”
OVER A PERIOD OF 1 HOUR IS MEASURED BY THE
LENGTH OF THE SEDIMENT RBC COLUMN
 EXPRESSED IN MILLIMETERS
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5. STAGES OF ESR
SEDIMENTATION OCCUR IN 3 STAGES
STAGE OF AGGREGATION (FORMATION OF A
NUMBER OF THINGS INTO A CLUSTER)/ROULEAUX
FORMATION :
IN THE INITIAL 10 MINUTES, THERE IS LITTLE
SEDIMENTATION AS ROULEAUX FORM AND THE
SIZE OF THE ROULEAUX FORMED INFLUENCED THE
SPEED OF SEDIMENTAION
STAGE OF SETTLING: FOR 40 MINUTES ,SETTLING
OCCURS AT A CONSTANT RATE
STAGE OF PACKING: PACKING OF RBCs OCCURS IN
THE FINAL 10 MINUTES
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6. ERYTHROCYTE SEDIMENTATION
RATE
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12. WINTROBE ESR - PROCEDURE
WHOLE BLOOD COLLECTED IN WINTROBE,S”
BALANCED OXALATE “ OR EDTA
USING THE SPECIAL PIPETTE,TRANSFER WELL
MIXED BLOOD FROM THE SAMPLE BOTTLE
FILL THE SPECIAL WINTROBE TUBE TO THE 0.0
MARK NEAR THE TOP OF THE TUBE
(THE TUBE CONTAIN ABOUT 1ml OF BLOOD)
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13. WINTROBE ESR – PROCEDURE
PLACE IT VERTICALLY IN THE STAND & NOTE THE
TIME
EXACTLY AFTER 1 HOUR,EXAMINE THE TUBE
NOTE THE READING OF THE LEVEL OF THE TOP
OF THE RBC COLUMN
THIS READING IN mm CORRESPONDS TO THE ESR
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14. ADVANTAGES
SIMPLE
REQUIRES SMALL AMOUNT OF BLOOD
SAME TUBE CAN BE USED FOR BOTH ESR AND
PCV
BUFFY COAT SMEAR IS USEFUL IN CASES OF
LEUKOPENIA
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15. DISADVANTAGE
• ESR VALUE HIGHER THAN PCV WHICH CAN NOT
BE OBTAINED BY THIS METHOD
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16. ALTERNATIVELY METHODS
CAPILLARY METHOD (MICRO ESR METHOD): REQUIRES
ONLY O.2 ml OF BLOOD
USEFUL IN PEDIATRIC PATIENTS
ZETA SEDIMENTATION RATE : SPECIAL DEVICE ZETAFUGE
IS USED
AUTOMATED ESR : RESULTS ARE OBTAINED WITHIN 30
MINUTES AND ARE COMPARABLE WITH WESTERGREN 1
HOUR READING
ESR STAT PLUS : CENTRIFUGATION –BASED METHOD
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17. WESTERGREN METHOD
• VERY SIMPLE
• COMMONLY USED METHOD
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19. WESTERGREN METHOD
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21. WESTERGREN ESR – PROCEDURE
A WESTERGREN PIPETTE IS FILLED UP TO THE “ZERO”
MARK
PLACED VERTICALLY IN THE WESTERGREN RACK AT
ROOM TEMPERATURE
AFTER 60 MINUTES,THE DISTANCE BETWEEN THE TOP
OF THE RED CELL COLUMN
“ZERO “ MARK IS NOTED IN MILLIMETERRS AS ESR
READINGS
 RESULT: ESR IS EXPRESSED AS mm AT THE END OF ONE
HOUR
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22. ADVANTAGE
MORE SENSITIVE
ACCURATE METHOD WHEN COMPARED TO THE
WINTROBE METHOD
BECAUSE THE COLUMN IS LONGER ,i.e 200 mm
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23. MODIFIED WESTERGREN
METHOD
• USES BLOOD WITH ANTICOAGULATED WITH EDTA
RATHER THAN WITH CITRATE
• PRODUCES THE SAME RESULTS
• ADVANTAGES – MORE CONVENIENT
• ESR CAN BE PERFORMED FROM THE SAME TUBE OF
BLOOD COLLECTED FOR OTHER HAEMATOLOGIC STUDIES
• ESR CAN BE TWO MILLIMETERS OF WELL –MIXED EDTA –
BLOOD IS DILUTED WITH 0.5 ml OF 3.8%SODIUM
CITRATE OR WITH 0.5 ml of 0.85% SODIUM CHLORIDE
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24. Revised normal range for ESR
AGE MEN WOMEN
Below 50 years 15mm/ hour 20mm/hour
Above 50 years 20mm/hour 30mm/hour
Above age 85
years
30mm/hour 42mm/hour
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25. SIGNIFICANCE OF ESR
• PROGNOSTIC TEST RATHER THAN A DIAGNOSTIC
TEST
• ESR IS ONE OF THE JONES MINOR CRITERIA FOR
THE DIAGNOSIS OF RHEUMATIC FEVER
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28. APPLICATION OF ESR & CLINICAL
SIGNIFICANCE
• SICKLE CELL DISEASE: LOW ESR IN THE ABSENCE OF
PAINFUL CRISIS AND MODERATELY RAISED 1 WEEK
INTO THE CRISIS
• OSTEOMYELITIS: ELEVATED AND USEFUL IN FOLLOW
UP
• STROKE: ESR≥28MM/HOUR IS POOR DIAGNOSTIC
FEATURE
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29. PHYSIOLOGICAL FACTORS INFLUENCING THE
RATE OF SEDIMENTAION
1.PLASMA FACTORS – AN ACCELERATED ESR IS FAVOURED BY
ELEVATED LEVELS GLOBULINS ,FIBROGEN AND CHOLESTEROL
2.NUMBER OF CELLS – INCREASES IN ANEMIA
DECREASES IN POLYCYTHEMIA
3.AGE - ESR IS LOW – CHILDHOOD
ELDER PEOPLE SLIGHTLY INCREASED
4.GENDER – ESR IS SLIGHTLY HIGHER IN WOMEN THAN MEN
DUE TO THE FACT THAT WOMEN TEND TO HAVE
SLIGHTLY LOWER PCV VALUES
5.PREGNANCY – ESR BEGINS TO INCREASE IN THIRD MONTH OF
PREGNANCY
RETURNS TO NORMAL 3-4 WEEKS AFTER DELIVERY
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30. APPLICATION OF ESR &
CLINICAL SIGNIFICANCE
• CANCER OF PROSTATE: ESR ≥ 37mm/hr IS ASSOCIATED
WITH HIGHER INCIDENCE OF DISEASE ( PROGRESSION AND
DEATH)
• PREGNANCY : ESR MODERATELY INCREASES BEGINNING AT
THE 10TH -12TH WEEK AND RETURN TO NORMAL ABOUT 1
MONTH POSTPARTUM
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31. LABORATORYFACTORSINFLUENCINGTHE
ESR
1.TEMPERATURE – SEDIMENTATION RATE IS INCREASED
AT HIGHER TEMPERATURE
NORMALLY PEOPLE HAVE A SLIGHTLY HIGHER ESR
ESR IS ALWAYS DONE AT ROOM TEMPERATURE
CARE SHOULD BE TAKEN THAT THE APPARATUS IS
NOT EXPOSED TO THE DIRECT RAYS OF THE SUN
COMING THROUGH A WINDOW OR TO SOME OTHER
SOURCE OF HEAT
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32. 2.TIME
 PROGRESSIVE
BLOOD HAS BEEN STANDING FOR MORE
THAN 4 HOURS
ESR WILL DECREASE CONSIDERABLY
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33. 3.ANTICOAGULANTS
INFLUENCE SEDIMENTATION
POTASSIUM OXALATE – SHRINKS THE CELL
AMMONIUM OXALATE – SWELLS THE CELLS
IF OXALATED BLOOD IS USED FOR THE ESR,IT
SHOULD ONLY BE BALANCED OXALATE OR
WINTROBE,S MIXTURE
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34. 4.THE LENGTH OF THE TUBE
ESR IS GREATER WITH LONGER TUBE
5.INCINATION OF THE TUBE
IF THE TUBE IS PLACED IN A RACK IN WHICH IT IS SLANTED
OR DEVIATED FROM THE VERTICAL
THE RATE OF SEDIMENTATION WILL BE INCREASED
ENSURE THAT THE TUBES ARE HELD EXACTLY VERTICALLY
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35. 6.MOVEMENT OR AGITATION OF THE TUBE
TUBE SHOULD BE HELD ON A TABLE WHICH IS
NOT BEING BUMPED OR VIBRATED
 SUCH EQUIPMENT AS CENTRIFUGES OR
SHAKERS AS AGITATION OF THE BLOOD DURING
THE PERIOD OF THE TEST
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37. LUPUS ERYTHEMATOUS CELL
TEST
• IN AUTOIMMUNE DISEASES (E.G.SLE, RHEUMATOID
ARTHRITIS)
• VARIETY OF ANTIBODIES ARE FOUND
• ONE OF THEM IS AN ANTINUCLEAR ANTIBODY (ANA)
WHICH CANNOT PENETRATE INTACT CELLS
• ANAS CAN REACT WITH NUCLEI OF DAMAGED CELLS &
CONVERT NUCLEAR CHROMATIN INTO HOMOGENOUS
MATERIAL
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38. LUPUS ERYTHEMATOUS CELL
TEST
• IN VIVO, ANAS ACT ON THE NUCLEI OF DAMAGED CELLS
AND DENATURES IT INTO HOMOGENOUS MATERIAL
• THIS NUCLEAR MATERIAL IS PHAGOCYTOSED IN THE
PRESENCE OF COMPLEMENTARY BY PHAGOCYTIC
LEUKOCYTE (NEUTROPHIL OR MACROPHAGES)
• LE CELL IS ANY PHAGOCYTIC LEUKOCYTE TISSUE THEY
ARE KNOWN AS LE BODIES OR HEMATOXYLIN BODIES .
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39. LUPUS ERYTHEMATOUS CELL
TEST
• Tart cell : LE cell has to be differentiated from a
tart cell
• It is a monocyte/neutrophil containing a
phagocytosed nucleus of another cell
• The nuclear material is not homogeneous and it
retains its chromatin pattern
• It may be found in healthy individuals
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40. PREVIOUS YEAR QUESTIONS
ESR (5 MARKS) APRIL 2017 ,FEB/MARCH 2011
FACTORS AFFECTING E.S.R (5 MARKS) FEB/MARCH 2012
E.S.R ESTIMATION BY WINTROBE’S METHOD (5 MARKS) FEB
2010
DEFINE ESR.DISCUSS VARIOUS METHODS OF ESR
ESTIMATION AND FACTORS INFLUENCING ESR .(AUGUST
2010 )
ESR – WHAT IS THE NAME OF THE INSTRUMENTS AND
ANTICOAGULANTS USED IN ESTIMATION OF E.S.R AND ITS
NORMAL VALUES IN MALES AND FEMALES? (3 MARKS)
AUG/SEP 2011
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41. PREVIOUS YEAR QUESTIONS
NAME THE ANTICOAGULANT USED IN ESR
AND ITS CONCENTRATION?(3 MARKS) SEP
2012
ESTIMATION OF ESR (5 MARKS)MARCH
2013
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