Acute pancreatitis (AP) is a common inflammatory disease which can be mild and self-limiting without complications or severe with prolonged hospitalization, high morbidity, and high mortality. Different radiological scoring systems to predict severity and outcome in AP have been developed since the early 1990s. In the meantime, new insights in the pathophysiology of AP and consequently, therapeutic management of these patients have been introduced. The purpose of this review is therefore (1) to describe the current terminology and new concepts in the pathophysiology, (2) to outline the long existing and newly developed radiological scoring systems in prediction of severity and outcome with their respective advantages and limitations, and (3) to define the role of radiological prognostic scoring systems in the new environment of perception of the last decade. Risk stratification in AP requires scoring systems that can be calculated early in the course of disease which allows time for intervention. For that reason, scoring systems based on necrosis are not useful in severity prediction. The recent developed radiological scoring systems based on signs of systemic inflammatory response syndrome and organ dysfunction are promising in prediction of severity early after onset of AP.