Severe acute pancreatitis continues to be a difficult problem in clinical management. This paper provides a contemporary definition of the condition and explores the controversial issues that surround its diagnosis and management.Review of pertinent English language literature.The use of various imaging techniques is discussed, with particular emphasis on the assessment of pancreatic necrosis and the evaluation of choledocholithiasis as a cause of the pancreatitis. Prophylactic antibiotics generally are discouraged and early and aggressive nutritional support is advocated. Delayed surgical intervention is recommended to avoid the severe consequences associated with prematurely early attempts at resection of the infarcted pancreas and adjacent retroperitoneal fat.Better quality evidence, especially regarding the utility or lack thereof of antibiotic prophylaxis, is beginning to inform optimal management of patients with severe acute pancreatitis.