Erythrocyte Sedimentation Rate (ESR): Principle, Methods

Erythrocyte Sedimentation Rate (ESR) can be described as a commonly used test used to detect non-specific signs of inflammation result of infection cancers, or certain autoimmune disorders. It is defined as the rate that Red Blood Cells (RBCs) accumulate over an hour.

Purpose of Erythrocyte Sedimentation Rate (ESR)

Sed rate tests can be beneficial when you are evaluating unresolved symptoms, such as arthritis and other symptoms that impact the muscles. They can also aid in confirming a diagnosis for certain ailments, for example:

  • Giant cell arteritis
  • Polymyalgia rheumatica
  • Rheumatoid arthritis

A sed-rate test can aid in determining the extent of your inflammation and track the effects of treatments.

Since a sed-rate test doesn’t identify the cause that’s causing inflammation within the body. It’s typically followed by tests for blood, like the C-reactive Protein (CRP) tests.


Principle of Erythrocyte Sedimentation Rate (ESR)

When anticoagulated blood is left to sit in a small, vertical glass tube without interruption for a time and then the RBCs under the influence of gravity – settle out from the plasma. The speed at which they settle can be measured by the millimeters that have clear plasma on the uppermost part of the column at the end of one hour(mm/hr). The mechanism is comprised of three steps:

  • Stage of aggregation:  It is the first step in which the accumulation of RBCs occurs. The process is referred to as the Rouleaux formation. It is observed in the initial 15 to 20 minutes.
  • Stage of sedimentation: Stage of sedimentation is the actual stage of sinking of RBCs, in which sedimentation happens at a constant rate. It can take 30 to 40 minutes from the time of one hour, based on the length of the tube is used.
  • Stage of packing: This is the last stage, and is also referred to as the stationary stage. There is slowing down of the rate in which the packing of the sedimented RBCs within the column happens due to the overcrowding. This occurs within the final 10 minutes of 1 hour.

Methods of Erythrocyte Sedimentation Rate (ESR) determination

There are two methods for determining ESR :

  • Wintrobe’s method
  • Westergren’s method

Each method yields very different outcomes that are slightly different. Mosely as well as Bull (1991) found that Wintrobe’s method was less sensitive when ESR is low. On the other hand in the event that ESR has been elevated, Westergren’s method should be considered an indicator of the patient’s medical condition.

Wintrobe’s method of Erythrocyte Sedimentation Rate (ESR)

This technique uses Wintrobe’s tube, which is a narrow glass tube that is closed just at the lower part. The Wintrobe’s tube is length of 11cm and its internal diameter is 2.5 millimeters.


It is comprised of 0.7-1 milliliters of blood. The lower 10 cm are measured in cm and millimeters. The marking is 0 at the uppermost point, and 10 in the lower to indicate ESR. The tube can also be utilized for PCV. Its marking is 10 on the top , and zero on the lowest for PCV.

Wintrobe’s method of Erythrocyte Sedimentation Rate (ESR)
Wintrobe’s method of Erythrocyte Sedimentation Rate (ESR)

Requirements for Wintrobe’s method

  • Anticoagulated blood (EDTA, double oxalate)
  • Pasteur pipette
  • Timer
  • Wintrobe’s tube
  • Wintrobe’s stand

Procedure of Wintrobe’s method

  1. Mix the blood anticoagulant thoroughly.
  2. Utilizing a Pasteur pipette. Fill up the Wintrobe’s tube until it reaches the “0” mark. There shouldn’t be any bubbling blood.
  3. Put the tube vertically into the ESR stand, and then leave it in place for 1 hour.
  4. At the end of one hour, check the result.

Normal values : For males : 0-9 mm/hr, For females 0-20 mm/hr


Westergren’s method of Erythrocyte Sedimentation Rate (ESR) 

It’s a superior method to Wintrobe’s method. The reading is magnified when the column lengthens. It is the Westregren tube opens on both ends. It measures 30 cm long and 2.5 millimeters in diameter. The lower 20cm are indicated with zero at the top and 200 at the bottom. It has about 2 ml of blood.

Westergren’s method of Erythrocyte Sedimentation Rate (ESR) 
Westergren’s method of Erythrocyte Sedimentation Rate (ESR) 

Requirements for Erythrocyte Sedimentation Rate (ESR) 

  • Anticoagulated blood (0.4 ml of 3.13% trisodium citrate solution + 1.6 ml blood)
  • Westergren tube
  • Westergren stand
  • Rubber bulb (sucker)

Procedure of Erythrocyte Sedimentation Rate (ESR) 

  1. Mix the blood with anticoagulation thoroughly.
  2. Inject the blood into the tube until it reaches 0 , using the help of a rubber bulb.
  3. Clean blood off the inside the tube using cotton.
  4. Place the tube upright on the stand. Check that the pipette fits well to avoid leakage, and ensure that the pipette is placed vertically.
  5. Allow the tube to remain uninhibited for 1 hour.
  6. After 1 hour, check the results.

Normal values: For males : 0-10 mm/hr, For females : 0-15 mm/hr


The Results and What They Mean

Your sample will be sent to the laboratory. You will receive the results within 1 or 2 hours.

A technician from the lab will put the red blood cells in an elongated, thin tube and then measure the distance they travel in one hour. If you are suffering from inflammation within your body, abnormal proteins found in your blood cause red blood cells grow into clusters. They are extremely large, and they sink into the tubes’ bottom faster than individual blood cells.

The faster blood cells shrink the more inflammation will be within your body.

The test for sed rate reports the millimeter scale (mm) how far you are from the transparent blue liquid (plasma) that is at the bottom of the tube, and your red blood cells following 1 hour. The typical range is:

  • between 0 and 15 mm/hour for men who are younger than 50
  • between 20 and 0 mm/hour for men over 50
  • between 20 and 0 mm/hour for women under 50
  • between 0 and 30 millimeters/hour for women over 50

A high rate of sedation could be an indicator of an illness that can cause inflammation in your body.

Certain conditions and medications could affect the speed that red blood cells decrease and may impact the results of your tests. They include:

  • Anemia
  • Older age
  • Kidney problems
  • Thyroid disease
  • Pregnancy or having your period
  • Obesity
  • Drugs such as birth control pills such as theophylline, methyldopa (Aldomet) and theophylline (Theo-24 Theolair Elixophylline) vitamins A and cortisone, as well as quinine.

Clinical Significance

Erythrocytes’ sedimentation rates (ESR) is an unspecific test. It is elevated across a range of inflammatory, infective malignant conditions that are triggered by variations in plasma proteins. including the increase in fibrinogen, immunoglobulins, as well as C-reactive protein.

The ESR is affected by a variety of other factors like anaemia, haemoglobinopathies, pregnancy and the treatment of anti-inflammatory drugs.

Causes of a significantly raised ESR 

  • All forms of anemias are included, with the exception of sickle cell anemia
  • Chronic and acute infections and inflammations, which include:
    • HIV disease
    • Tuberculosis
    • Acute viral hepatitis
    • Arthritis
    • Bacterial endocarditis
    • Pelvic inflammatory disease
    • Ruptured ectopic pregnancy
    • Systemic lupus erythematosus
    • African trypanosomiasis (rises rapidly)
  • Visceral leishmaniasis
  • Myelomatosis and lymphoma, Hodgkins disease, certain tumors
  • Oral contraceptives, for example, are among the drugs available.

Causes of Reduced ESR

  • Polycythaemia
  • Poikilocytosis
  • Newborn infants
  • Dehydration
  • Dengue haemorrhagic fever
  • Other conditions associated with haemoconcentration

Medical uses of Erythrocyte Sedimentation Rate (ESR)


  • ESR is sometimes useful for diagnosing certain diseases that are not easily diagnosed, like multiple myeloma and temporal arteritis polymyalgia-rheumatica, a variety of auto-immune conditions, systemic Lupus the erythematosus, arthritis rheumatoid, chronic inflammatory bowel disease, and kidney disorders.
  • It is typically used for the purpose of determining if Kawasaki’s Disease (from Takayasu’s Arteritis, that would be characterized by an raised ESR) and may be increased in chronic infectious conditions such as tuberculosis as well as infective endocarditis.

The severity of the disease

  • It is a part of the PCDAI (pediatric Crohn’s disease activity index) which is an indicator for assessing an extent of the impact of the diseases for children.

Monitoring response to therapy

  • The clinical utility of ESR is restricted to monitoring the response to treatment for certain inflammation-related diseases like the temporal arteritis, polymyalgia Rheumatica and rheumatoid joint arthritis.
  • It is also employed as a rough indicator of response in Hodgkin’s Lymphoma.
  • Furthermore, ESR levels are used to identify one of various possible adverse prognostic indicators in the diagnosis of Hodgkin’s lymphoma.

Frequently Asked Questions

Q1. What can it be used for?

An ESR test will help you determine whether you suffer from a condition which causes inflammation. It can be a sign of vasculitis, arthritis or inflammatory bowel disease. ESRs are also used to detect inflammatory bowel disease. ESR could also be utilized to detect an existing problem.

Q2. What is the reason I require an ESR?

Your physician might order an ESR in case you are suffering from symptoms of an inflammation disorder. This includes:

  • Headaches
  • Fever
  • Weight loss
  • Joint stiffness
  • Neck or shoulder pain
  • Loss of appetite
  • Anemia

Q3. What is the process that takes place during ESR?

A medical professional will draw an in-person specimen of blood from the vein inside your arm using an extremely tiny needle. When the needle is introduced into the vein, a small amount blood is taken and placed in an vial or test tube. There may be a slight pain when the needle is inserted through or out. It usually lasts less than five minutes.

Q4. Will I need to do anything to prepare for an ESR?

You don’t require any particular preparations for this test.

Q5. Are there any dangers to the test?

There is a very low chance of developing an ESR. There is a possibility of slight discomfort or bruises at the site in which the needle was placed into, however most of the symptoms disappear in a matter of minutes.

Q6. What are the results?

If you’re ESR is elevated It could be due to an inflammation condition like:

  • Infection
  • Rheumatoid arthritis
  • Rheumatic fever
  • Vascular disease
  • Inflammatory bowel disease
  • Heart disease
  • Kidney disease
  • Certain cancers

Sometimes, the ESR may be lower than usual. A slow ESR could be a sign of an illness of the blood for example:

  • Polycythemia
  • Sickle cell anemia
  • Leukocytosis, an abnormal increase in white blood cells

If your results aren’t within normal limits however, this doesn’t suggest that you have an illness which requires treatment. A moderate ESR could indicate menstrual irregularity, pregnancy or anemia, but it’s not more than an inflammatory condition. Certain medications and supplements may influence the results. This includes oral contraceptives, cortisone, aspirin, and vitamins A. Make sure you inform your doctor about any medications or supplements you’re taking.



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