Acute pancreatitis remains a serious illness. Most patients with persisting organ failure have necrotizing rather than interstitial pancreatitis. Necrotizing pancreatitis can be distinguished from interstitial pancreatitis on incremental dynamic bolus CT scan. Infected necrosis can be diagnosed by guided percutaneous aspiration with Gram stain and culture. The treatment is surgical debridement. Patients with sterile necrosis associated with organ failure may have a high mortality rate. It remains unclear at present whether such patients should be treated by early surgical debridement or continuation of medical therapy. Measures that may be helpful in the future in reducing morbidity and mortality include the use of newer inhibitors of proteases and phospholipase-A2, inhibitors of other mediators of inflammation, and methods to improve the microcirculation of the pancreas.