Severe acute pancreatitis causes high rates of illness and death. Simple scoring predictors can help identify patients at risk so that treatment, primarily supportive, can begin promptly after presentation. Medical therapy is the mainstay, with supportive therapy consisting of controlled volume resuscitation and enteral feeding. Minimally invasive drainage and debridement play a role in managing infective pancreatic necrosis but in general should not be used until at least 4 weeks after the acute illness.