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The revised Atlanta Classification of Acute Pancreatitis classifies severity into mild, moderately severe and severe using both clinical and radiographic criteria (Table 1.4) [59]. In mild AP, patients usually improve rapidly with supportive care (fluid resuscitation) and mortality is rare, except in patients with severe comorbidity [60]. Patients with acute mild pancreatitis by definition do not have local complications such as peripancreatic collection, sterile pancreatic necrosis, and exacerbation of a comorbidity, and they do not have a modified Marshall score of 2 or more that defines the presence of organ failure (respiratory, renal, cardiovascular) [59].

Moderately severe AP is defined as the presence of transitory organ system failure (<48 hours) and/or local or systemic complications exacerbating comorbid disease without persistent organ failure [59]. Severe AP is characterized by single or multiple organ failure for longer than 48 hours, determined by analysis of the respiratory, renal and/or cardiovascular systems using the modified Marshall scoring system. Patients with persistent SIRS for longer than 48 hours, or with infected necrosis, are usually in this category, although infected necrosis can be present without organ failure. (Table 1.5).

Table 1.4 Classification of acute pancreatitis.

Source: adapted from Banks et al. [59].

	Mild	Moderate	Severe
Organ failure	None	Transient (resolves within 48 hours)	Persistent organ failure (>48 hours) of one or more organs
Local complications	None	Yes, without persistent organ failure
Systemic complications	None	Yes, without persistent organ failure

Table 1.5 Predictors of severe acute pancreatitis.

Source: adapted from Forsmark et al. [52].

Patient	Age, obesity (BMI >30), altered mental status, numerous and severe comorbidities including coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus, chronic liver disease, long history of alcohol abuse
SIRS	Present and persists >48 hours
Laboratory	Hematocrit >44% and no decrease with hydration Urea nitrogen >20 mg/dl (>7.1 mmol/l) rising and/or no decrease with hydration, and/or elevated creatinine >1.8 mg/dl (>159 mmol/l)
Imaging	Pleural effusion or infiltrates