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1
ESR Test
Sh Barawy
LOGO
Test Description
•The erythrocyte sedimentation rate (ESR) is a nonspecific test ,
it is measure of the presence and severity of pathological processes
•It is used in inflammatory and necrotic conditions.
•It is easy to perform, widely used screening test
•Although the test has been used since 1926 the phenomenon of red
cell sedimentation is still only partly understood.
• It is also used a monitoring tool for response to treatment in
conditions in which it is raised (tuberculosis, autoimmune diseases
,cancer and *
• It may also be increased in some physiologic cases, such as
pregnancy and menstruation * .
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2
ESR Test
Sh Barawy
LOGO
1-
In these types of conditions, there is a change in blood proteins,
which leads to a clumping of red blood cells.
2- The ESR is referring balance between pro-sedimentation factors, mainly fibrinogen,
and resistant sedimentation factor that related with negative charges on surfaces of
RBCs, which repel each other. *
3- When an inflammatory process is present, the high rate of fibrinogen in the blood
causes red blood cells to stick to each other. The red cells form stacks called 'rouleaux,'
which settle faster.
4- The aggregation of RBCs into rouleaux, which fibrinogen’
s positive charge decreases
the RBCs ’
zeta potential, leading to clumping RBC together that increased rouleaux and
an increased ESR. *
5-The ESR measures the speed with which erythrocytes settle in a tube of blood which
has been mixed with an anticoagulant. Cells that have clumped due to inflammatory and
necrotic conditions settle more rapidly than single cells.
6- The ESR, expressed in mm/h *
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3
ESR Test
Sh Barawy
LOGO
ESR Test
Sh Barawy
4
clumping of red blood cells
LOGO
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Three phases can be distinguished in the sedimentation
process.
v The initial lag phase (10 minute)
. The rates of aggregation and sedimentation are displaying of the instability of a
blood suspension, which is depend on a mutual effect between the red blood cell
membrane surface and certain plasma proteins; these proteins have been called “
agglomerins.”that mainly fibrinogen
v The phase of rapid RBC falling(40m)
The plasma-red cell interface falls more rapidly (increasing sedimentation)
vThe packing phase (10m)
the red cell aggregates fall down and arranged on the bottom of the tube ;
sedimentation slows down as a result of mutual interference of the closely packed
aggregates. Thus, if the descent of the plasma-red cell interface is plotted against
time .
5
ESR Test
Sh Barawy
LOGO
ESR Test
Sh Barawy
6
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LOGO
Factors Affecting ESR
v
Plasma properties
§
Acute-phase proteins
§
Increased proteins
cause rouleaux
The aggregated RBCs in the
rouleaux formation have a higher
ratio of 'mass to surface area' as
compared to single RBCs and
hence sink faster in plasma .
7
ESR Test
Sh Barawy
LOGO
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•Adult
•Male < His Age
2
•Female < Her Age +10
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•The result measured by mm/hr
•
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8
ESR Test
Sh Barawy
LOGO
Age
20 years
55 years
90 years
Men
10mm/hr
23 mm/hr
45 mm/hr
Women
15 mm/hr
30 mm/hr
50 mm/hr
9
ESR Test
Sh Barawy
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A-Rate of Plasma Protein:
during inflammation and tissue injury which occurred
by some of diseases increase the concentration of
fibrinogen and Immunoglobulin all have “
agglomerin”
properties will increase rouleaux formation so as the
result increases RBC sedimentation. While plasma
albumin decrease sedimentation of RBCs .
B-The number and properties of Red Blood Cells
:
the number , size ,shape and biconcavity of RBC that
show alterations affect on ESR
1- RBC size : microcytes tend to settle slower than
normal cells, while macrocytes fall more rapidly.
2- RBC Shape : An increase in spherocytes or sickle
cells red cells decrease the sedimentation
3- RBC number :Increase red cell mass will retard the
sedimentation rate such as . polycythemia
10
ESR Test
Sh Barawy
LOGO
ESR Test
Sh Barawy
11
Abnormal RBC
Normal RBC
LOGO
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v
The ESR should not be used to screen asymptomatic patients for
disease.
v
To screen for certain disease conditions such as arteritis, rheumatoid
arthritis, and polymyalgia rheumatica.
v
To differentiate among diseases with similar symptoms
v
To serve as an index to disease severity
v
To monitor the course of an existing disease.
v
To monitor a patient’
s response to treatment :useful in monitoring the
progression of inflammatory diseases; if the patient is being treated with
steroids, the ESR will decrease with clinical improvement.
12
ESR Test
Sh Barawy
The ESR is a nonspecific indicator of inflammation and necrosis. Since The
sedimentation rate is not diagnostic of any particular disease but rather is an
indication that a disease process is ongoing and must be investigated.
LOGO
Possible Meanings of Abnormal Values
Increased
Anemia
Pain
Coccidioidomycosis
Hemolytic anemia
Increased Fibrinogen
Increased Plasma Globulins
Infection acute or chronic
Inflammatory process
Malignancies and cancer
Multiple myeloma
Myocardial infarction
Osteomyelitis
Polymyalgia rheumatica
Rheumatoid arthritis
Tissue injury
Tuberculosis
Decreased
Factor V deficiency
Hyper albuminemia
Polycythemia vera
Sickle cell anemia
Congestive heart failure
Hyper blood viscosity
Decreased fibrinogen levels
< 0.5 mm/hr
Note
: ESR of more than 100 mm/hr is strongly associated with serious underlying
disorders like connective tissue disease, infections and malignancies
13
ESR Test
Sh Barawy
LOGO
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•
The ESR may be increased during menstruation, after the 12th week of
pregnancy, and postpartum.
•The ESR may be decreased in the presence of elevated white blood cell
count, albumin, and lipids.
•Drugs which may increase the ESR: such as heparin , dextran,
methyldopa (Aldomet), oral contraceptives, penicillamine procainamide,
theophylline, and vitamin A
•Drugs which may decrease the ESR: albumin, aspirin, corticotropin,
cortisone,
steroids and quinine
14
ESR Test
Sh Barawy
LOGO
Substitute for esr
15
ESR Test
Sh Barawy
Ø the C-Reactive Protein (CRP) test is a much better indicator of
inflammation than the ESR.
Ø CRP is the actual protein being produced a nd the CRP determines
the amount of protein present and is not affected by anemia or abnormal
serum proteins.
Ø Generally, ESR does not change as rapidly as does CRP, either at the
start of inflammation or as it goes away.
Ø However, the ESR remains a very popular test to indicate the
presence of inflammation and necrosis, and is relatively inexpensive.
LOGO
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The anticoagulant
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used in this method is 3.8% tri-sodium citrate
solution.
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16
ESR Test
Sh Barawy
LOGO
ü There are two methods of measuring the ESR,
called t he West ergren and Wintrobe methods (Moore,
1999).
ü ESR was measured by Westergren tub e m ethod.
ü The Win tergreen method employs a 200 mm, 2.5
mm diameter tub e v ert ically aligned c olumn .
ü
Th e c olumn is filled wit h b lood ant ic oagulat ed
With (K3EDTA).
ü The distance that the column of blood falls in o ne
hour is Rec orded and reported in mm /h at the end of
1st hour .
üThe Wintrobe method employs a shor ter tu be
(100mm) and a different anticoagulant (ammonium
Oxide and pot ass ium oxalate).
17
ESR Test
Sh Barawy
LOGO
Ø
A venous blo od s ample was then t aken
f rom t he patien t's ar m.
ØEach patient were taken 2 ml of blo od from
by a disposable s yrin ge.
Ø The blood samples dropped to heparinzed
t ube .
Ø Each tube was labeled with the per son
ident if ic ation, name, date of birt h and sex of
the patient
ØAdd each tub e b lood sample 0.5 ml of 3.8%
of sodium citrat e for ESR.
ØFill the pipette by sucking blood up to 0 marks and fix
it vertically in Westergren stand. Read the upper level of
RBC column exactly after 1 hr.
2
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18
ESR Test
Sh Barawy
LOGO
Procedure
19
ESR Test
Sh Barawy
LOGO
Principle of ESR test
20
ESR Test
Sh Barawy
LOGO
Technical
Factors Affecting ESR
v
Temperature : higher temperature ,ore than room
tempprature cause false high results due to reduction
in plasma viscosity
v
Time
v
Tube diameter and length
v
Pipetting technique
v
Position of tube
v
Vibrations cans reduce the ESR
21
ESR Test
Sh Barawy
LOGO
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:
:
1- NCCLS. Reference and Selected Procedure for the Erythrocyte Sedimentation
Rate (ESR) Test; Approved Standard—Fifth Edition. NCCLS document H2-A4
(ISBN 1-56238-424-4). NCCLS, 940 West Valley Road, Suite 1400, Wayne,
Pennsylvania ( 2011 )
2- EDUCATIONAL COMMENTARY –THE ERYTHROCYTE SEDIMENTATION RATE
AND ITS CLINICAL UTILITY , American Proficiency Institute –2006
3- The Erythrocyte Sedimentation Rate: old and new clinical applications C.
Saadeh
4- CRP & ESR testing: When to use which? RR Mechatronics B.V. 2014
5- Why Shouldn’
t We Determine the Erythrocyte Sedimentation Rate? Rafael L.
Jurado Clinical Infectious Diseases 2001
22
ESR Test
Sh Barawy