Panic findings in the gastrointestinal tract do not include emergency findings. There are three semi-urgent findings: “intestinal dilatation with loss of peristalsis,” “multiple concentric ring sign,” and “free air.” The presence or absence of precipitation of contents should also be checked to determine the loss of peristalsis. If there is a direct suspicion of strangulated bowel obstruction, this should be reported. If it is difficult to distinguish it from simple bowel obstruction or ileus, one should not force the distinction. The most common causes of strangulated bowel obstruction are hernia impaction, compression by a cord, and torsion, many of which form a closed loop obstruction. Exceptions include Richter’s hernia and intussusception. The multiple concentric ring sign is a characteristic ultrasonography finding in intussusception. In children, more than 90% of cases are idiopathic without organic disease, and the ileocolon type is common, while in adults, about 70% of cases present with a tumor as a pathologically advanced site. More than 90% of free air is due to gastrointestinal perforation, which can be caused by ischemic bowel disease, peptic ulcer, malignancy, acute appendicitis, or diverticulitis of the colon. Free air ultrasound images are recognized by strong echoes caused by gas reflections and artifacts such as multiple reflections and comet-like echoes that occur behind them. When the volume is small, it is often impossible to detect gastrointestinal perforation unless the examiner actively looks for it.

In recent years, physiological examinations such as ultrasonography, as well as specimen tests, are increasingly performed by non-doctors in medical facilities, and more examinations are being performed outside of laboratories. In the laboratory, there is an “emergency response system” widely known clinically as “panic values”. The list of panic values and their communication system are created and established through discussions between the medical and laboratory sides. When an ultrasound finding is judged to be urgent, diagnosis and treatment must be performed promptly. When a patient is diagnosed with an urgent disease based on ultrasound findings, treatment commensurate with the urgency and severity of the diagnosed disease is required. It should be noted that the functions of doctors and non-doctors such as laboratory technicians and nurses (hereinafter referred to as medical staff) are different. While doctors can diagnose and treat a patient immediately based on findings, medical staff can recognize/report images and findings and request confirmation, but they cannot diagnose or treat a patient. However, if candidates for images/findings that should be considered for serious conditions/diseases requiring attention are clearly indicated in advance, medical staff can recognize “candidate images/findings requiring attention” and promptly report and request confirmation from a doctor. The level of urgency varies depending on the severity of the disease, and two levels of urgency, i.e., “urgent” and “semi-urgent,” plus “early” have been proposed. It is necessary to establish an “emergency reporting system” for each facility, and it is expected that the system will be examined (modified, expanded, etc.) and verified according to the actual situation at each site, and that it will be widely used and be useful in clinical practice. In order to ensure that the “Critical/Panic Findings System” is widely used in clinical practice, it is also essential that the “Critical/Panic Findings System” be well known to medical staff and doctors in the field.

“Panic Findings: Abnormal Findings Requiring Urgent Action” in ultrasonography was published by the Japanese Society of Ultrasound in Medicine. We herein explain the key points of ultrasound panic findings in the urological region. “Urgent findings” in the urological region include fluid retention in the retroperitoneal cavity with internal echogenic spots, caused by renal trauma or rupture of renal tumor, etc. Due to the anatomical characteristics of the kidney being in the retroperitoneum and surrounded by Gerota’s fascia, the mortality rate without immediate treatment is low. By checking ultrasound findings along with vital signs, it is likely that in many cases a urological finding can be treated as a “semi-urgent finding”. There are two “semi-urgent findings” in the urological region. One is dilation of both renal pelvises (calyxes). Extrarenal dilation, where only the renal pelvis is dilated, does not need to be considered a panic finding. If one kidney is non-functioning, dilation of the contralateral renal pelvis and calyx is also a panic finding. The other “semi-urgent finding” is a mass lesion (fluid collection with internal echo) accompanied by fever or tenderness. In renal infection accompanied by fever and tenderness, along with a mass (fluid collection with internal echo), intrarenal emphysema, or renal pelvic distention with debris, is considered a “semi-urgent finding.”

When performing ultrasonography (US) on patients with acute abdomen, it is efficient and useful to rule out more urgent diseases while paying attention to the patients’ response and exacerbation in vital signs first, then screen for more frequent diseases as speculated based on abdominal symptoms, age, and sex. The “Panic Findings: Abnormal Findings Requiring Urgent Action” (panic findings) presented by the Japan Society of Ultrasonics in Medicine classifies abnormal findings in US that should be reported immediately into three groups: 1) “Urgent findings” requiring immediate action, 2) “Semi-urgent findings” requiring prompt action, and 3) “Abnormal findings” requiring early action. “Urgent findings” related to the hepatobiliary-pancreatic region include peritoneal/retroperitoneal fluid collection with debris echo, corresponding to intra-abdominal bleeding, organ damage, and rupture of tumors such as hepatocellular carcinoma. On the other hand, “semi-emergent findings” include multiple solid mass lesions or cluster signs (multiple liver metastases), liver mass lesions with fever and tenderness (liver abscess), extrahepatic bile duct dilation with fever (acute cholangitis), intrahepatic bile duct dilation (obstructive jaundice), enlarged gallbladder with fluid retention (acute cholecystitis), and enlarged pancreas with fluid retention (acute pancreatitis). These panic findings will enable rapid and reliable screening for emergency illness in patients with acute abdomen, which will prevent sudden deterioration of the patients’ condition (death) and contribute to improving the prognosis of emergency patients.

Gynecological disorders are included in the differential diagnosis of acute abdomen. In particular, gynecological disorders such as ectopic pregnancies, ovarian hemorrhage, and torsion of ovarian tumor can remain asymptomatic but can become serious if they progress, so caution is required. It is important to understand the characteristics of these diseases and the signs that should not be overlooked.

“Panic findings” are abnormal observations that may pose a life-threatening risk, requiring an appropriate response. According to the guidelines issued by the Japan Society of Ultrasonics in Medicine in November 2023, panic findings should not merely be considered abnormal observations but should function as an integral part of an emergency response system established by each facility. Ultrasound examinations are often performed by sonographers, who must remain composed when encountering abnormal findings. Echocardiographic examinations are particularly critical as they can detect life-threatening cardiac abnormalities, necessitating immediate action upon identifying a panic finding. Before the examination, it is essential to understand the request and review the latest information, such as the ECG. When a panic finding is discovered, if the patient exhibits symptoms or hemodynamic abnormalities, the sonographer should immediately contact a physician. If the patient is asymptomatic and hemodynamically stable, it is advisable to compare the current findings with previous results to determine the appropriate response. Diseases requiring immediate response/reporting include acute coronary syndrome, cardiac tamponade, acute aortic dissection, acute pulmonary embolism, intracardiac thrombus, cardiac tumors, infective endocarditis, ventricular septal rupture, pseudoaneurysm, papillary muscle or chordae tendineae rupture with acute severe mitral regurgitation, left ventricular outflow tract obstruction, and severe arrhythmias. Diseases requiring prompt reporting include prosthetic valve dysfunction, new onset or acute exacerbation of heart failure, and newly discovered severe valvular disease. In the case of cardiovascular diseases, timely intervention significantly impacts patient outcomes. The panic finding system is crucial for ensuring patient safety, and each facility must establish a system tailored to its specific circumstances.