Patients with severe acute pancreatitis (SAP) present complications and organ failure, which require treatment in critical care units. These extrapancreatic complications determine the clinical outcome of the disease. Intra-abdominal hypertension (IAH) deteriorates the prognosis of SAP. In this paper, relevant recent literature was reviewed, as well as the authors’ own experiences, concerning the clinical importance of IAH and its treatment in SAP. The principal observations confirmed that IAH is a frequent consequence of SAP but is practically absent in mild disease. Common manifestations of AP such as pain, abdominal distension, and paralytic ileus contribute to increased abdominal pressure, as well as fluid loss in third space and aggressive fluid replacement therapy. A severe increase in IAP can evolve to abdominal compartment syndrome and new onset organ failure. Conservative measures are useful, but invasive interventions are necessary in several cases. Percutaneous drainage of major collections is preferred when possible, but open decompressive laparotomy is the final possibility in some cases in order to definitively reduce abdominal pressure. Intra-abdominal pressure should be measured in all SAP cases that worsen despite adequate treatment in critical care units. Conservative measures must be introduced to treat IAH, including negative fluid balance, digestive decompression by gastric–rectal tube, and prokinetics, including neostigmine. In the case of insufficient responses to these measures, minimally invasive interventions should be preferred.

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Autoimmune pancreatitis is a relatively recently identified entity. The dominant type 1 is the pancreatic manifestation of a systemic IgG4-related fibroinflammatory disease. The type 2 has a clearly different histology, its dominant feature is a granulocytic epithelial lesion, and it is independent of IgG4. While type 1 is rather a disease with male dominance in majors than 50-year-old people, no gender difference is observed in type 2, and the disease is more frequently seen in young people. The more frequent initial clinical manifestation is obstructive jaundice in type 1, while abdominal pain and mild acute pancreatitis in type 2. CT and magnetic resonance images are very similar, IgG4 can be normal even in type 1, and the associated involvement of other organs is frequently posterior to the pancreatic manifestation; thus, the distinction of the two types of AIP can be difficult without histology in the everyday clinical practice. Several cases can be undetermined and qualified as Not Otherwise Specified (NOS). However, all types of AIP respond quickly to steroid treatment with a complete recovery. Late prognosis is good, but up to 50% recurrence has been observed in type 1, and several authors have described progression to chronic pancreatitis.