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SummaryBackground: Abdominal pain of uncertain aetiology (non-specific abdominal pain; NSAP) is the commonest reason for emergency surgical admission. The aim of this study was to examine the role of early laparoscopy in the management of NSAP. Methods: Some 120 patients, admitted between November 1995 and October 1998 with acute abdominal pain of uncertain aetiology, were randomized into two groups: group 1 had laparoscopy during the first 18 h of admission and group 2 had close observation, conventional investigation and surgical intervention if signs of peritonism developed. Outcome measures were diagnosis, operative procedures, duration of hospital stay, readmission rate, morbidity and death, patient satisfaction and total number of investigations performed. Results: Median hospital stay was 2 (range 1–13) days in both groups (P = 0·87). A diagnosis was established in 48 (81 per cent) of 59 patients in group 1 compared with 22 (36 per cent) of 61 in group 2 (P < 0·0001). The morbidity rate was 14 (24 per cent) of 59 in group 1 and 19 (31 per cent) of 61 in group 2 (P = 0·3629). The readmission rate at a median follow-up of 21 (range 1–35) months was 17 (29 per cent) of 59 in group 1 compared with 20 (33 per cent) of 61 in group 2 (P = 0·6375). Well-being scores improved from 134 on admission to 149 of 177 6 weeks later in group 1 (P = 0·007) and from 132 to 143 of 177 in group 2 (P = 0·089). Conclusion: Early laparoscopy provided a higher diagnostic accuracy and improved quality of life in patients with NSAP. [ABSTRACT FROM AUTHOR]