To clarify the relationship of aspiration pneumonia (ASP) to feeding gastrostomy in neurologically disabled patients, we reviewed the charts of 87 patients who had a feeding gastrostomy for enteral access. We looked for evidence of gastroesophageal reflux (GER) and ASP. Prior to gastrostomy, the frequency of ASP was 29 of 87 patients. One year after gastrostomy, the crude frequency of ASP (17 of 52 patients) was not significantly improved. After gastrostomy, ASP was still observed in 18 of the 29 patients in whom ASP had been identified prior to gastrostomy. In the 58 patients in whom there was no clinical evidence of ASP prior to gastrostomy, 17 demonstrated ASP after gastrostomy. Over-all, 39 of 87 patients died. Mortality at one year (32) was greater in patients with documented ASP (p = 0.025). The preoperative presence of GER was associated with postoperative ASP (predictive value of 0.70). The preoperative presence of both GER and ASP was associated with postoperative ASP in all of the patients we studied.