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EBMG

Elevated Esr (Hypersedimentation)

Essentials

  • Erythrocyte sedimentation rate (ESR) means the rate (mm/h) at which erythrocytes settle at the bottom of a test tube in the patient's own plasma.
  • ESR is principally dependent on the concentration of plasma fibrinogen.
  • The ESR indirectly reflects the concentration of the acute phase proteins in the plasma. Its value may significantly be affected by the number, size and morphology of erythrocytes as well as the amount of other plasma components, for example immunoglobulins. Anaemia and decreased blood protein concentration increase ESR.
  • The significance of a slightly elevated ESR value is difficult to assess, particularly in the elderly. The threshold for starting investigations should be set considerably higher if the patient remains asymptomatic or if the ESR has not clearly increased from previous readings.
  • The level of the ESR is dependent on the activity of the disease, and it is often a useful investigation when monitoring disease progress. In many situations the CRP concentration decreases along with the disease activity, but the ESR remains high, sometimes permanently, because of hypergammaglobulinaemia.

Reference values

  • See table T1.

Reference values for ESR, mm/h

Age, yearsMen, mm/hWomen, mm/h
0-161-151-15
17-29<10<20
30-39<15<25
40-49<20<25
50-59<25<30
60-69<25<35
70-79<30<40
Over 80<35<45

Diseases with ESR nearly always elevated

Diseases with ESR often elevated

Diseases with ESR relatively often normal

  • Most cancers, particularly those of the gastrointestinal tract
  • Osteoarthritis
  • Viral infections
  • The ESR is usually low in polycythaemia (even in diseases that usually raise the ESR).

Assessment of the patient

  • Symptomatic patients should be appropriately investigated to diagnose the underlying disease. The nature of the symptoms determines the urgency of the investigations.
  • In asymptomatic patients or patients with minimal symptoms, it should be determined whether the ESR has steadily increased from the normal value, and what is the direction of change. If the ESR is markedly elevated (more than 20 mm/h above the upper reference value) further investigations should be planned as follows.

Medical history

  • The patient should always be asked about
    • fever
    • worsening of the general health status
    • unintended weight loss
    • local symptoms (pain, tenderness)
    • joint symptoms (particularly morning stiffness) and myalgias; also earlier episodes
    • bowel habits, consistency of the stools
    • cough, sputum
    • history of tuberculosis.

Investigations

  • General physical examination, particularly lymph nodes, thyroid gland, skin, lungs, abdomen, joints, teeth
  • If the history of the patient does not suggest any particular diagnosis, the following examinations should be carried out:
    • complete blood count with differential leucocyte count
    • urinalysis and bacterial culture
    • plasma CRP
    • plasma ALT, alkaline phosphatase
    • plasma creatinine
    • plasma calcium (albumin corrected)
    • serum protein electrophoresis (differentiation between polyclonal and monoclonal increase in the gammaglobulin concentration) and serum light chains
    • plasma rheumatoid factor and serum anti-CCP antibody assays (if the patient has joint symptoms)
    • imaging examinations on a discretionary basis according to the clinical situation (e.g. chest x-ray, sinus x-ray, abdominal ultrasound scan)
    • fine needle and other biopsies.

Indications for hospital investigations in hypersedimentation of unknown origin

  • If the general condition of the patient is markedly affected the investigations should be started immediately.
  • Asymptomatic young or middle-aged patients should be referred after the aforementioned investigations if the ESR remains elevated. A very high ESR (> 80 mm/h) is an indication for more urgent investigations.
  • In elderly patients the general situation determines the scope of the investigations. Sometimes no investigations are necessary after serious diseases and, more importantly, treatable conditions have been excluded.

    References

    • Bray C, Bell LN, Liang H, et al. Erythrocyte Sedimentation Rate and C-reactive Protein Measurements and Their Relevance in Clinical Medicine. WMJ 2016;115(6):317-21. [PubMed]
    • Ramsay ES, Lerman MA. How to use the erythrocyte sedimentation rate in paediatrics. Arch Dis Child Educ Pract Ed 2015;100(1):30-6. [PubMed]
    • Batlivala SP. Focus on diagnosis: the erythrocyte sedimentation rate and the C-reactive protein test. Pediatr Rev 2009;30(2):72-4. [PubMed]
    • Brigden M. The erythrocyte sedimentation rate. Still a helpful test when used judiciously. Postgrad Med 1998 May;103(5):257-62, 272-4. [PubMed]