Background/Aims: Severe acute pancreatitis ( SAP) is associated with a high morbidity and mortality. The aim was to evaluate treatment, risk factors and outcome in SAP in a centre with a restrictive attitude to surgery. Methods: All cases of acute pancreatitis admitted 1994 - 2003 were analysed retrospectively. SAP was defined as organ failure and/or hospital stay > 7 days together with one or more of: C-reactive protein > 150 mg/l within 72 h after admission, necrosis on computed tomography and need for treatment in the intensive care unit. Results: 185 (22%) of patients with acute pancreatitis fulfilled the criteria for SAP. 175 patients were included, mean age 61 +/- 17 years. Hospital stay was in median 13 days. Forty-six patients had some surgical intervention, in 14 cases directed at the pancreas (8%). Hospital mortality was 9% (n = 16), in 88% ( n = 14) associated with multiple organ dysfunction and 50% ( n = 8) of the deaths occurred within the first week after admission. Of the parameters registered on admission, age and hypotension (systolic blood pressure < 100 mm Hg) were identified as risk factors for death. Conclusion: The present treatment regime for SAP as defined above resulted in a 9% mortality rate, with age and hypotension at admission as predictive factors for death.