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While aspiration and feeding difficulties are well known challenges in the intensive care unit, their pathophysiology has been poorly understood. New information suggests that the critically ill are subject to profound alterations in motor and sensory function of the oesophagus, lower oesophageal sphincter, stomach, and duodenum which go some way to explaining their propensity to reflux and gastroparesis, with their attendant risks A s medicine changes so should all aspects of medical care and knowledge; as more and more patients are subjected to surgical proce-dures of increasing complexity and risk and as survival rates from catastrophic illness rise, due to advances in surgery