Indicative of digestive imbalance and intestinal stress due to enzyme deficiencies or inappropriate diet. This includes consumption of fast food, “dead food” and foods not suitable for the blood type.


Rouleau is French for “rolls”. The term has been derived from the appearance of the RBCs in this condition.

Strings of overlapping RBC’s. RBC’s stacked on top of one another.

RBCs overlapping in a “curved coin roll” appearance

Very tightly stacked RBCs in long strands throughout the sample.

The RBCs can appear flattened out like stacked books.This is a much more serious finding and indicates severe digestive imbalance, chronic degenerative disease, advanced endobiosis or all three.



In most samples, there will be some rouleau formations (usually at the periphery). However, when we see rouleau in the majority of the sample, with only a small percentage of RBCs not overlapping, the finding is significant. The degree of overlapping may also vary from loosely stacked cells (mild rouleau) to very tightly stacked cells (severe rouleau), as illustrated in the picture.



♦ Digestive Imbalance / Intestinal Stress.

♦ This is the worst stage of protein linkage and indicates hyperviscosity (“thick blood”).

♦ It correlates with excess protein in the blood due to poor protein digestion and assimilation.

This stems from either excess dietary protein or from an under-active exocrine pancreas (low proteolytic enzyme production).

♦ Irritable bowel syndrome, colitis.

♦ Eating the wrong foods for the blood type, e.g. wheat consumption by type O’s, beef consumption by type A’s, etc.

♦ Food sensitivities.

♦ Intestinal dysbiosis (deficient probiotic bacteria).

♦ Can be an indication of severe degenerative disease.

♦ Other causes may include: stress, coffee, cigarettes, carbonated caffeinated drinks, excess meat and refined sugar.

♦ Zeta potential may be off (inflammation, over-acidity and increased protein level in blood).

♦ Dehydration, not drinking enough water.


Associated Symptoms:

♦ Poor appetite or a heavy/bloated sensation after eating or getting full very quickly.

♦ Heartburn, indigestion or reflux after eating.

♦ Abdominal discomfort, bloating, flatulence, especially getting worse during the course of the day.

♦ Constipation / diarrhea.

♦ Patients with significant rouleau usually complain of fatigue, shortness of breath and signs of poor circulation (cold hands and feet, tingling or numbness). This is because the RBCs ability to pass through the tiny capillaries in a single file is severely compromised when they are stacked on top of each other. The available surface area for the exchange of gases is also significantly reduced.


Pleomorphic Perspective:

The primary parasitic element of the blood, the endobiont, in its many different forms, possesses an inherent urge to merge. When red blood cells become infested with the higher valence growth forms of the primary parasite, their urge to merge pulls the RBCs together. Copulation between high valence microorganisms on adjacent RBC membranes accounts for the rouleau formations.

Rouleau is known to be associated with increased ESR, which correlates with hyperviscosity of the blood. Mucor racemosus Fresen is known as the congester as its pathogenic growth forms increase blood viscosity and coagulation. When the RBCs are stuck together the indentations provide an undisturbed environment and nutritional reserves for the upward development of the endobiont. The valence of the microorganisms can be determined by pressing lightly on the cover slip with a pointed object like the tip of a pen. This pressurization of the sample will break up the

RBCs and release higher growth forms hidden in and on the cells.


Medical Perspective:

Peripheral blood smears display rouleau when factors that increase ESR (erythrocyte sedimentation rate) are present. The ESR is increased by any cause or focus of inflammation and is therefore regarded as a non-specific indication of inflammation.

The ESR is governed by the balance between pro-sedimentation factors (mainly fibrinogen) and those factors resisting sedimentation, namely the negative charge of the erythrocytes (zeta potential). When an inflammatory process is present, the increase in fibrinogen, α-globulins, and/or β-globulins in the blood causes red blood cells to stick to each other by interacting with the sialic acid on the RBC surface. The red cells form stacks called ‘rouleau’ that settle faster.

The presence of massive rouleau can be detrimental to patients suffering from occlusive vascular diseases as it causes impairment of blood flow in the small vessels that can compromise the red blood cells’ ability to exchange carbon dioxide and oxygen gases. This results in localized hypoxia and acidosis as well as generalized fatigue and less than optimum performance.

Rouleau formation plays a specific role in the pathogenesis of some disease. Plasma fibrinogen and Immunoglobulins are some of the potent rouleau-inducing agents. Some industrial poisons such as benzene, parathion & carbon tetrachloride not only increase this phenomenon but also cause thrombotic and hemorrhagic manifestations as well. Patients suffering from allergies, infections and severe trauma may exhibit rouleau. Anemia, by increasing the ratio of RBCs to plasma, increases rouleau formation and accelerates sedimentation. Rouleau formation can also occur in association with some lymphoproliferative disorders in which one or moreimmunoglobulins are secreted in high amounts. Rouleau formation can, however, be a normal physiological finding in horses, cats and pigs.

Rouleau of erythrocytes is related to very high serum protein concentrations, generally due to multiple myeloma or to macroglobulinemia. It is also frequently found in many disease states ranging from arthritis, diabetes, myocardial infarction and in patients with increased alcohol intake.



♦ Reduce intake of dietary animal protein to 1g per kg body weight per day (e.g.: a 70kg adult should not exceed 70g animal protein daily).

♦ Do not consume animal protein and simple starch in the same meal.

♦ Eat meals while sitting down, do not rush while eating – remember to chew properly.

♦ Follow the diet relevant to the blood type.

♦ Identify and avoid hidden food sensitivities.

♦ Avoid caffeine, stop smoking.

♦ Test and correct Homocysteine.

♦ Increase water intake. To determine necessary daily water intake (in litres): (Weight in kg ÷ 8) x 0.25.

A combination of the following:

♦ Digestive enzymes taken with main meals.

♦ Betaine Hydrochloride with Pepsin with meals.

♦ Probiotic supplement.

♦ Herbal bitters (e.g. Gentiana) taken before meals. The following is a very effective formula to stimulate digestive enzyme, bile and HCl secretion:

Gentian, Calamus, Dandelion, Centaury, Aniseed, Mugwort and Licorice.

♦ TCM: Si Jun Zi Tang, Bao He Wan, or another digestive formula appropriate to the pattern present in the case.

♦ Vitamin B3, as non-flush Niacin (1000mg daily). Niacin helps to remove excess protein and saturated fat from the blood and stimulates hydrochloric acid production by the stomach.

♦ Trace minerals.

♦ SANUM: Fortakehl, followed by Mucokehl.


Working with Rouleau:

The majority of clients displaying rouleau have some digestive imbalance and digestive symptoms.

Always ask the client about their digestive system and whether they experience any symptoms there. Where symptoms can not be elicited, correlate with other signs to determine the underlying imbalance. Although rouleau may be an indication of advanced degenerative disease, the approach is usually to first attempt to reestablish the correct terrain through nutritional interventions. These include dietary changes (as listed above), digestive enzymes, probiotics, vitamin B3 and alkalinizing formulae (base powders, green powders). Generally, this approach is effective in reversing rouleau. However, if the condition persists, consider further conventional investigations.


Further Investigations:

♦ FBC + differential + ESR

♦ Urea, Electrolytes & Creatinine (UE+C)

♦ LFT + Globulin

♦ Lipogram (fasting) + Homocysteine

♦ Glucose (fasting) + Insulin / GTT (Glucose Tolerance Test) + Insulin

♦ C-reactive protein

♦ D-Dimer (alternative to FDP – Fibrinogen Degradation Products)

♦ Serum protein electrophoresis

♦ Quantitative Immunoglobulins

♦ Immunoelectrophoresis

♦ RF (Rheumatoid Factor) + ANF (Antinuclear Factor)

♦ Cardiac Enzymes (AST + LDH + CK + CKMB + Troponin-T)

♦ Hepatitis Screen

♦ Thyroid Function Test

♦ TNF (Tumor Necrosis Factor) + Tumor markers

♦ Food sensitivity assay (IgG)

♦ IgE + Phadiotop (inhalant allergens) + Fx5 (Food allergy test)


Note: As rouleau may be caused by acute phase protein elevations in the blood, the possibility of serious disease complications exist when it does not respond to nutritional therapy. If rouleau does not disappear after the appropriate nutritional treatment and there is no evident tissue inflammation, tissue damage or tissue necrosis, additional testing can be conducted to rule out arthritis, arthritis, cholecystitis, cirrhosis, diabetes, endocarditis, rheumatic diseases, rheumatic heart disease, hepatitis, hyperthyroidism, chronic infection, nephritis, systemic lupus, ulcer, colitis and neoplastic disease.

Copyright Dr Okker R. Botha, Johannesburg, South Africa, 2009