Intestinal fistula, a formidable complication in the late stage of severe acute pancreatitis (SAP), significantly elevates mortality through mechanisms including intra-abdominal infection induction, exacerbation of homeostatic imbalances, and increased nutritional risk. Its pathogenesis is multifactorial, involving mechanical compression/enzymatic erosion by peripancreatic necrotic tissues, intestinal ischemia and iatrogenic injury from invasive interventions. Early diagnosis requires a heightened clinical awareness and the judicious use of diagnostic modalities, including computed tomography (CT), fistulography, and endoscopy, to delineate the anatomical location of the fistula. Surgical management adheres to a staged therapeutic paradigm: during the conservative treatment phase, infection source control remains the cornerstone, supplemented by enteral nutrition, organ function support, and other adjunctive measures to promote spontaneous fistula closure; in the definitive surgical phase, the therapeutic approach is dictated by the anatomical location of the fistula, with conservative management prioritized for upper gastrointestinal fistulas, such as those involving the stomach and duodenum, and more aggressive surgical intervention for colonic fistulas.