LM of rouleaux (singular is rouleau) stacks or aggregations of red blood cells (RBCs) which form because of the unique discoid shape of the cells in vertebrates. The flat surface of the discoid RBCs gives them a large surface area to make contact with and stick to each other; thus forming a rouleau. They occur when the plasma protein concentration is high, and because of them the ESR (erythrocyte sedimentation rate) is also increased. This is a non-specific indicator of the presence of disease. The stacking occurs because red blood cells have large flat surface that enable them to stick together. Conditions that lead to this include infections, inflammatory disorders, cancer, diabetes and anemia.