Objective: To give an overview of the current management of severe acute pancreatitis focusing on prophylaxis, nutrition, imaging and intervention. Search strategy: PUBMED, EMBASE and Cochrane database search for clinical studies and guidelines regarding severe acute pancreatitis published in the last five years (from January 1 2002). Ongoing studies of the Dutch Acute Pancreatitis Study Group are summarized. Summary of findings: The four most important changes in the management of severe acute pancreatitis in recent years are; a) to refrain from giving antibiotic prophylaxis in necrotizing pancreatitis; b) to use enteral nutrition instead of parenteral nutrition whenever possible; c) to use descriptive terms when describing computed tomography findings rather than interpretative definitions such as 'pseudocyst' and 'pancreatic abscess'; d) a strong tendency to postpone intervention, even in cases of suspected or documented infected pancreatic necrosis. In an attempt to improve diagnosis, treatment and outcome of severe acute pancreatitis, the Dutch Acute Pancreatitis Study Group has chosen to perform nationwide randomized trials in patients with infected necrotizing pancreatitis specifically with respect to these issues. Conclusion: In the third millennium the treatment of severe acute pancreatitis has shifted from routine antibiotic prophylaxis, parenteral nutrition, and early operation to tailored antibiotic treatment, enteral nutrition, and postponing of radiological and surgical intervention. Copyright © 2008, Nederlandse Vereniging voor Intensive Care. All Rights Reserved.