In the management of patients who present to the accident and emergency department with acute abdominal pain the casualty officer has three options: to treat and discharge, to refer to the out-patient department or to refer for urgent admission. The early management of 512 adults presenting to one accident and emergency department with acute abdominal pain has been prospectively studied to determine the accuracy of the casualty officers' decisions as opposed to diagnostic accuracy. Of the 512 patients, 333 (65%) were discharged home with no further hospital follow-up having been arranged; of these 18 (5%) returned with persistent symptoms and five (2%) were admitted. Of 132 patients referred for urgent admission 113 (85.6%) were either admitted or further investigated and were followed up as out-patients. This study demonstrates a high accuracy of decision making by relatively junior hospital staff in the management of acute abdominal pain.