After the skin, the gastrointestinal tract is the second most common target of systemic sclerosis. The major clinical manifestations include gastroesophageal reflux, small bowel bacterial overgrowth, malnutrition, and intestinal pseudoobstruction. Treatment is symptomatic and supportive. Gastroesophageal reflux can usually be adequately managed with prokinetic drugs, omeprazole, and judicious use of antireflux surgery. If Barrett's esophagus is present, periodic endoscopic monitoring for development of dysplastic changes or adenocarcinoma is indicated. Bacterial overgrowth usually responds to rotating antibiotics and prokinetic drugs. Malnutrition and intestinal pseudoobstruction remain the major problems and often home total parenteral nutrition is required. Intestinal pseudoobstruction occurs in two phases: an early, neuropathic phase may respond to prokinetic drugs (metoclopramide, cisapride, octreotide, and erythromycin) and dietary modification (low-residue diets, vitamin supplementation). In the late myopathic phase, therapy is usually ineffective. Treatment consists of nutritional support. Careful manometric and radiographic localization of affected segments of stomach and small and large intestines may allow judicious surgical resection or venting procedures to reduce symptoms in this unfortunate group of patients.