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cases, endoscopic retrograde cholangiopancreatography (ERCP) may be performed for both diagnostic and therapeutic indications ( Fig 103.8 ) Severe injury of the pancreas is rare, but when it occurs, blood loss and leakage of enzyme-laden secretions may result in hypovolemia and peritonitis Blunt abdominal trauma may also injure the ductal elements of the pancreas, and diagnosis depends on a high index of suspicion, consideration of the mechanism of injury, physical examination, serum amylase determination, and diagnostic imaging Of note, however, is that the absence of hyperamylasemia does not preclude pancreatic trauma Serum amylase level may be normal in 30% of patients with complete transaction, whereas elevated serum amylase level is detected in 14% to 80% of cases of blunt injury Elevated serum amylase level should suggest the possibility of pancreatic involvement, but the absolute value does not correlate with the degree of injury Hyperamylasemia may be present with pancreatic injury, but its absence does not preclude injury In one study, elevations of amylase level more than 200 U/L and lipase level more than 1,800 U/L were markers of possible major pancreatic ductal disruption In a more recent retrospective study, elevations of amylase and lipase levels were infrequently detected in patients with blunt abdominal trauma (4% and 7%, respectively), and neither the sensitivity nor negative predictive values of elevated measurements were sufficient to be used as screening tools for pancreatic injury Pancreatic injury is difficult to diagnose, particularly since a CT scan of the abdomen is only 60% to 70% accurate in identifying pancreatic injury