The Evolution of SIBO: From Paradigm Shift to Postbiotic Future

SIBO As An Entry to Microbiome Science

I still remember the moment SIBO flipped a switch in my brain. I had just left the world of academic molecular biology—where mechanisms mattered but patients didn’t exist—and was early in my naturopathic medical training, wrestling with the frustrating ambiguity of IBS. “It’s stress,” we were told. “Try fiber. Try peppermint.” It all felt too vague. But then, in a gastroenterology lecture, my mentor Dr. Steven Sandberg-Lewis introduced the concept of Small Intestinal Bacterial Overgrowth (SIBO) as a concrete, testable mechanism underlying IBS symptoms. That was it. Suddenly, the scattered threads of chronic bloating, abdominal pain, and bowel dysfunction wove into something intelligible. There were gases. There were pathways. There was a test. And there was a treatment.

As a student with a molecular lens and a patient’s heart, this was the bridge I needed. SIBO was the first clinical concept that gave me a reason to fall in love with the microbiome—not just as an abstract ecosystem, but as a living, metabolic system that could explain suffering in human terms. I dove into everything I could find connecting microbial metabolism to gut function and systemic disease. Breath tests, hydrogen curves, methane flares—it was elegant and messy and human.

In clinic, those early SIBO cases became turning points. Instead of managing IBS symptoms with generic recommendations, we could investigate whether misplaced microbes were the culprits. Watching patients improve—sometimes dramatically—after a targeted course of treatment was profoundly validating. Those experiences, and the mentorship I received from Dr. Sandberg-Lewis and Dr. Megan Taylor, cemented my path. SIBO wasn’t a fad; it was a reframing. It showed me that chronic illness often holds deeper logic—and that by asking better questions, we could find it.

SIBO 101: Understanding the Basics

So, what exactly is SIBO? Small Intestinal Bacterial Overgrowth means an excessive amount of bacteria populating the small intestine, beyond the normal minimal levels. In a healthy gut, the majority of our trillions of microbes live in the colon (large intestine), not the small intestine. But if bacteria accumulate and replicate in the small intestine beyond what’s normal, we call it SIBO . This overgrowth can happen for various reasons (more on that later), and it turns the small intestine into a fermentation chamber.

Why is that a problem? Think of the digestive tract as having designated zones: the small intestine is for absorbing nutrients from food after digestion, and the colon is for fermenting and metabolizing the nutritious plant material we didn't absorb earlier (fiber, etc.). The friendly bacteria in our colon ferment foods to produce beneficial compounds – what we here at Thaena think of as postbiotics like short-chain fatty acids (SCFAs) that nourish our gut lining. However, in SIBO those bacteria are misplaced into the small intestine. When they ferment foods there (especially carbohydrates we eat), gas is produced in an area not designed to handle it. The result: painful bloating, lots of belching or flatulence, and disrupted bowel habits ranging from diarrhea to constipation. Essentially, SIBO hijacks the normal digestive process, causing symptoms that mirror IBS (in fact, SIBO is now thought to underlie a large fraction of IBS cases). One landmark statistic that grabbed attention was that up to 75% of IBS patients may actually have SIBO. For many patients, treating the bacterial overgrowth leads to significant symptom improvement – a huge deal in a field where IBS was once treated only with dietary fiber or antidepressants.

How do we test for SIBO? The introduction of the breath test was a game-changer. SIBO is typically diagnosed with a non-invasive hydrogen–methane breath test. The patient drinks a sugar solution (like lactulose or glucose), and if there are too many bacteria in the small intestine, those microbes will ferment the sugar and produce gases (hydrogen, methane, and/or hydrogen sulfide). These gases are absorbed into the bloodstream and exhaled in the breath. By collecting breath samples every 15-20 minutes for a few hours, we can detect an early rise in gases that indicates fermentation happening too soon (i.e. in the small intestine rather than the colon). This gives a numeric, objective measure that both doctor and patient can see – at last, an IBS-related condition with a test result! Breath testing brought much-needed structure and legitimacy: IBS sufferers could finally prove an organic issue, and practitioners had a target to treat.

As SIBO gained traction in the functional medicine world, a few key voices helped bring structure, education, and visibility to the condition—both for clinicians and the broader wellness community. Dr. Allison Siebecker played a central role in this early movement, compiling research, clinical protocols, and dietary frameworks into what became SIBOinfo.com, one of the most trusted educational resources in the space. Her work on the SIBO Specific Diet provided clinicians and patients with a practical starting point for dietary management, and she has been a respected educator and clinical mentor to many in the field, myself included.

In parallel, Shivan Sarna built SIBO SOS®, a platform that expanded patient advocacy and education through interviews, masterclasses, and collaborative programs with experts like Dr. Siebecker. Their work together has helped shape how both patients and practitioners access information and navigate care, particularly in a landscape where formal GI support is often limited.

Bringing Structure to IBS Treatment: Alongside breath testing, clear treatment protocols emerged. If positive, a SIBO breath test might be followed by:

• Targeted antimicrobials: The antibiotic rifaximin became famous for IBS-D (diarrhea-predominant IBS) after clinical trials showed it could relieve symptoms – hinting it was wiping out excess bacteria. Herbal antimicrobials (like oregano oil, berberine, allicin garlic extracts) were adopted by integrative doctors as alternatives and showed comparable success in some studies.
  
  

• Dietary strategies: Diets like the Low-FODMAP diet or Dr. Siebecker’s specific SIBO diets help reduce fermentable substrates that feed bacteria. Many patients get relief from bloating by temporarily cutting down high-FODMAP foods (like lactose, legumes, certain fruits, grains). It’s a bit of a nutritional tightrope – you starve the bacteria without starving the patient – but it can make a big difference in symptom control.
  
  

• Prokinetics and digestives: Early SIBO protocols quickly recognized that killing bacteria wasn’t enough; you have to keep them from just coming back. This is where prokinetics (medications or supplements that improve the cleansing waves of intestinal motility) and digestive support (stomach acid, bile, enzymes) became crucial. SIBO often develops due to sluggish motility or low digestive secretions, so supporting these can prevent a relapse. For example, a bedtime dose of a prokinetic (like low-dose erythromycin or herbal ginger combos) helps sweep the small intestine clear nightly, using the body’s natural “cleaning waves” (migrating motor complex). Likewise, ensuring adequate stomach acid or bile flow can keep bacterial counts in check.
  
  

All of a sudden, what used to be a murky IBS consult now had a flowchart: test for SIBO → treat SIBO → dramatic symptom improvement → prevent recurrence. Patients often felt hope for the first time in years because we weren’t just telling them to “reduce stress and eat more fiber” – we were providing relief. The SIBO framework gave both patients and providers a game plan.

From Niche Idea to Mainstream – and the Lessons Learned

In the early 2010s, SIBO was largely the realm of functional and naturopathic medicine. GI specialists in conventional clinics were often skeptical or simply unaware of it. That began to change as research by gastroenterologists like Dr. Mark Pimentel at Cedars-Sinai brought SIBO into the mainstream spotlight. Rifaximin’s success in clinical trials for IBS-D (leading to FDA approval in 2015) was a watershed moment – it implicitly validated the infectious/bacterial theory of IBS. Suddenly, SIBO wasn’t so fringe. Gastroenterology conferences featured talks on breath testing, and journals debated how significant SIBO really was in IBS. Within a decade, we saw a real evolution: from “SIBO isn’t a real thing” to major journals publishing SIBO research and professional societies crafting guidelines on how to test and treat it.

However, this journey has not been without controversy. As SIBO moved from a functional medicine tool to a widespread concept, critiques and complexities emerged:

• Diagnostic Debates: Breath testing, while useful, is not a perfect diagnostic tool. Critics pointed out that lactulose breath tests in particular can give false positives – if a person’s gut transit is fast, the test might read fermentation from the colon a bit early and mistakenly suggest SIBO . A recent review noted that the lactulose breath test is basically a rough measure of how fast the sugar moves through your intestines, rather than a precise measure of bacterial location. On the other hand, glucose breath tests (which only detect bacteria in the upper small intestine because glucose gets absorbed before reaching the colon) may miss SIBO further down. Even the gold-standard diagnostic (aspirating fluid from the small intestine and culturing bacteria) has its pitfalls and is impractical for routine use. The result: ongoing debate in the GI community about how to define and diagnose SIBO. Some experts advocate for careful use of breath tests, while others remain skeptical and think many “SIBO” diagnoses in IBS are false positives.
  
  

• Relapse and Underlying Causes: Another hard lesson was that SIBO tends to relapse if we don’t fix why it happened in the first place. Studies show about 45% of patients will have SIBO recur after antibiotic therapy – in practice, some clinicians report even higher recurrence rates (50-65% within a year). Early SIBO treatment approaches sometimes ignored this, leading to a frustrating cycle for patients: test positive, take antibiotics, feel better, then months later symptoms creep back and the breath test is positive again. We learned that you have to zoom out and treat the underlying factors (poor motility, low stomach acid, hormones etc.). If someone keeps relapsing, it’s a clue that we need to address those root issues more aggressively (for instance, using prokinetic meds long-term, or managing conditions like hypothyroid, diabetes, or adhesions that can predispose to SIBO). It also taught us that SIBO might not be a one-off “infection” to eradicate, but rather a chronic condition to manage by nurturing a healthier gut environment.
  
  

• Broadening Perspectives: Some critiques went even deeper – questioning whether SIBO was the cause of IBS or just a correlated phenomenon. A 2024 review by Dr. Purna Kashyap and colleagues (Mayo Clinic) pointed out that after two decades of research, the SIBO-IBS hypothesis is still unproven in a definitive way. They argue that an over-emphasis on SIBO led to overuse of antibiotics in IBS without solving the core problem. This is a valid concern: not every IBS case is SIBO, and even in SIBO patients, nuking bacteria might not address things like visceral hypersensitivity (a sensitive nervous system) driving pain. The field has had to humbly admit that IBS is multifactorial – microbes are only one piece of a very complex puzzle involving the gut-brain axis, immune system, diet, and more.
  
  

In my own practice, I observed this complexity firsthand. Some patients would get dramatically better after SIBO treatment – it was like night and day for those whose main issue was bacterial metabolism and “simple” dysbiosis. But others would only improve 30-40%, or would relapse despite doing “everything right.” This forced me to expand my view and integrate other therapies (from stress management and nervous system support to bile acid supplements or antifungals) depending on the case. SIBO taught us a lot, but it wasn’t the whole story. And the more we think we learn the less we know. 

More Than Microbes: A Holistic Take on IBS (Insights from Megan Taylor, ND)

One of the most rewarding shifts in GI care that SIBO brought about is a more holistic, patient-centered approach to chronic digestive illness. I recently interviewed Dr. Megan Taylor, ND, a functional gastroenterology expert, about how SIBO changed the clinical landscape. Her insights resonated deeply, reinforcing what many of us have learned over the past decade:

• Validating Patients’ Suffering: Dr. Taylor shared a case of a patient who had suffered IBS symptoms for years without relief. The patient had been told by multiple doctors that “nothing is wrong” despite debilitating bloating and alternating diarrhea/constipation. When finally a breath test confirmed SIBO, the patient felt validated – “It’s real. I’m not crazy.” – and with treatment, she improved. This kind of story has played out countless times. SIBO gave clinicians a language to legitimize IBS and offer targeted relief. The gratitude from patients who finally feel heard (and better!) is immeasurable.
  
  

• Beyond Antibiotics – Looking at the Whole Pie: Both Dr. Taylor and I have learned that treating SIBO is not as simple as “find bacteria, kill bacteria, done.” She uses a brilliant “pie chart” analogy for IBS/SIBO, where each slice of the pie is a contributing factor to the patient’s symptoms. Microbial overgrowth is just one slice. Other slices might be: impaired motility, dysregulated stress response or past trauma, mast cell activation and histamine issues, leaky gut or immune activation, enzyme or bile deficiencies, visceral hypersensitivity, and so on. In some patients, SIBO (the bugs and their gas) might be 50% of the pie – so antimicrobials help a lot. But if the other 50% is, say, post-infectious nerve damage affecting motility and a history of early-life trauma keeping the nervous system on high alert, those need attention too. This pie model urges us to assess all the pieces: Is this patient’s migrating motor complex working? Could hidden food intolerances or fungal overgrowth be compounding symptoms? What about stress and the gut-brain connection?
  
  

• Case in point – motility and trauma: One common duo Dr. Taylor highlighted is the combination of slow motility and nervous system dysfunction. We often see patients who did have SIBO, got it treated, but still experience significant pain or bloating. In many of these cases, visceral hypersensitivity is at play – essentially the gut nerves are amplified, perceiving normal digestion as pain. This can be driven by past psychological trauma or chronic stress; the brain-gut axis stays in fight-or-flight mode. So even if we clear the bacteria, the patient might still feel awful because their nervous system is dialed up to 11. For such patients, solutions like gut-directed hypnotherapy, psychotherapy aimed at trauma, or neuromodulator medications can be life-changing. Similarly, if a patient’s underlying issue is severe dysmotility (for example, after food poisoning some people get damaged nerves in the gut, a condition known as post-infectious IBS), no amount of oregano oil will prevent SIBO from coming back – we must address the motility with prokinetics or therapies like abdominal vagus nerve stimulation. The bottom line: lasting success comes from treating the person as an ecosystem, not just nuking a bug.
  
  

• The Limitations of the “Kill Bugs” Approach: Early on, many of us (myself included) were a bit overly zealous with antimicrobials. If a patient had SIBO, we’d hit it hard with antibiotics or herbals, sometimes multiple rounds. But as Dr. Taylor noted, more is not always better – and can sometimes be worse. Repeated antibiotics can disrupt the larger microbiome, potentially leading to yeast overgrowth or other imbalances. Plus, some patients simply don’t tolerate these meds well. Over time, the strategy has shifted to be more nuanced: yes, reduce the overgrowth, but also simultaneously support digestion, diet, and the nervous/immune system so that we’re building health while removing the bad. In fact, some patients do better with gentle approaches (like a partial elemental diet, which is a liquid diet that starves bacteria, combined with probiotics and prokinetics) rather than numerous antibiotic cycles. We’ve learned to listen to the patient’s body and adjust course rather than following a rigid protocol.
  
  

Dr. Taylor’s perspective encapsulates what I consider the maturing of SIBO treatment: it started as an exciting new hammer for IBS, but we eventually realized not everything is a nail. Now our approach is more integrative – we still use the hammer, but we also bring out the screwdriver, the wrench, and sometimes the glue to fix the whole machine.

New Microbiome Insights: It’s Not Just Which Bugs – It’s What They’re Doing

While clinicians like me were refining our approach in practice, the scientific world continued to unravel deeper complexities of the gut. The microbiome revolution of the last 5-10 years has added layers of understanding that directly impact SIBO and IBS care. I had the fortune to attend Digestive Disease Week (DDW) 2023, one of the largest GI conferences, and the cutting-edge research presented there was both humbling and thrilling. Here are some of the key insights and advancements that are shaping the future of how we think about SIBO and gut health:

• Microbial Metabolism Takes Center Stage: A major theme is that what gut bacteria do (their function) may matter more than which species are present. In SIBO and IBS research, there’s growing focus on microbial metabolites – the substances microbes produce by breaking down our food or interacting with our body. Key players include:
  
  

• Bile acids: Bacteria in the small intestine can modify bile acids (which our liver produces to digest fats). These modified bile acids aren’t just for digestion – they act as signaling molecules. Some promote intestinal fluid secretion and speed up motility, while others slow things down. Bile acids can even affect pain sensation in the gut. Too much bacterial action on bile (as can happen in SIBO) can lead to irritating byproducts that cause diarrhea and inflammation. Conversely, certain healthy gut microbes convert bile into forms that signal the colon to absorb water properly and calm inflammation. Researchers at DDW discussed how imbalances in bile acid metabolism might explain IBS subtypes (for example, some IBS-D patients have excess bile in the colon causing diarrhea).
  
  

• Short-chain fatty acids (SCFAs): These are well-known “postbiotic” molecules (e.g. acetate, propionate, butyrate) produced when fiber is fermented, mostly in the colon. SCFAs are generally beneficial – butyrate is the preferred fuel for colon cells and has anti-inflammatory effects. Interestingly, SCFAs also influence gut-brain communication: they can stimulate the vagus nerve and modulate serotonin release, affecting motility and even mood. In the context of SIBO, if fermentation is happening excessively in the small intestine, the pattern of SCFA production might change in ways that could contribute to symptoms (propionate, for instance, can speed up transit and might contribute to urgency). There’s also evidence SCFAs can regulate the enteric nervous system, essentially tuning the excitability of gut neurons – a potential link to the visceral hypersensitivity we see in post-SIBO patients.
  
  
  

• Gas and beyond: We typically classify SIBO by the gas it produces – hydrogen SIBO vs methane SIBO vs the newer hydrogen sulfide type. These gases themselves are metabolites that affect us: methane, produced by Archaea organisms, slows intestinal transit (causing constipation) and can alter nerve signaling; hydrogen sulfide (the rotten-egg gas) at high levels can damage the gut lining and is linked to diarrhea. New breath tests now measure all three gases, and microbiome science is investigating why certain people’s flora produce more of one gas. It turns out diet and genetics might play a role. Also, beyond gas, microbes produce a slew of other signaling molecules – for example, histamine (from certain bacteria) can trigger pain and inflammation, and lipopolysaccharide (LPS) from bacterial cell walls can provoke immune reactions if it breaches the gut barrier. All these pieces are being studied as part of the “metabolomic profile” of SIBO and IBS.
  
  

• Microbiome-Host Crosstalk: Another insight is how intimately the microbiome interacts with our bodies. The bacteria aren’t just in a vacuum; they constantly exchange signals with the immune system and nervous system in the gut. Some highlights:
  
  

• Immune signals: Researchers are mapping how SIBO might tip the immune balance in the small intestine. A mild overgrowth might chronically activate the immune system, leading to low-grade inflammation that perpetuates gut lining damage or visceral hypersensitivity. There’s interest in markers like mast cells (immune cells that release histamine and can cause IBS-like symptoms when activated) being higher in some SIBO/IBS patients. This ties back to that pie chart – in some individuals, an immune overactivation (maybe due to an initial infection or ongoing imbalance) could be a key slice of the pie maintaining their symptoms.
  
  

• Motility feedback loops: The gut microbes can actually influence motility via byproducts that interact with the enteric nervous system. For instance, certain microbes stimulate the release of serotonin in the gut (most of our body’s serotonin is in the GI tract!), which in turn affects muscle contractions. Conversely, if the gut is moving too slowly (due to vagus nerve issues or diabetes neuropathy, etc.), bacteria get more time to multiply – so motility and microbes influence each other. Therapies like prokinetics might thus be helping not just by moving bugs out, but by altering microbial activity (less stagnation, less fermentation).
  
  

• Mucosal integrity: The health of the gut lining (mucosa) is partly maintained by microbial metabolites like butyrate. In SIBO, if the balance of these metabolites is off, the mucous layer and tight junctions between cells could be compromised, contributing to the infamous “leaky gut.” At DDW, there were posters on how certain probiotic strains or postbiotic supplements can directly improve the gut barrier. This is exciting because it suggests we might target gut permeability in SIBO patients to reduce their food sensitivities and systemic symptoms.
  
  

• Advanced Testing – Metabolomics and More: With the rise of high-tech analytic methods, we’re moving toward metabolomics in clinical practice. Metabolomics is basically measuring a broad array of chemicals (metabolites) in a sample. New stool and urine tests that measure things like bile acid fractions, SCFA levels, and even neurotransmitter metabolites are in development. One project featured at the conference was using mass spectrometry combined with big databases (like the MassIVE repository and others) to identify novel compounds in the gut that we’ve never seen before. Imagine being able to take a patient’s sample and not just see what microbes are there (DNA sequencing can do that), but also see a fingerprint of their biochemical activity. We could find, for example, that a patient’s microbiome is producing too little butyrate and too many sulfide compounds, and tailor a therapy to correct that balance of function. This is a leap beyond current stool tests, which mostly report microbial names. It aligns with a growing consensus: microbiome treatment should be guided by function (what needs fixing – e.g. inflammation, low SCFA, etc.) rather than just killing a specific bug.
  
  

All of these insights push us to evolve from a simplistic view of SIBO (“bad bacteria in small intestine = IBS”) to a more nuanced view of the gut as an ecosystem. It’s not that the old view was wrong; it’s that it was incomplete. Yes, eliminating an overgrowth can be necessary, but we also have to restore a healthy ecosystem – one that includes a balanced microbiota and a responsive, not hyper-reactive, gut environment.

The Road Ahead: From Eradication to Ecological Balance

Reflecting on this journey – from my first SIBO case a decade ago to the latest science in 2025 – it’s clear that the future of gut health is about balance over blind eradication. We’re moving away from the idea that we must wage war on bugs at all costs. Instead, the goal is to rebalance the gut ecosystem and restore normal function.

What might this look like in practice? For one, treatments will likely become more ecologically targeted. Rather than giving repeated broad antibiotics, we might use precise interventions like postbiotics or prebiotics to nudge the microbiome in the right direction. Postbiotics are the beneficial compounds produced by microbes (or even inactivated microbes themselves) that can modulate our health. For example, instead of trying to kill a hydrogen-producing bacteria, we might supplement a methanogen-balancing postbiotic or a butyrate-producing formulation that naturally crowds out the problem microbes by changing the environment they live in. This could break the vicious cycle of killing bacteria only to have them return.

My own work has been focused in developing and understanding ThaenaBiotic, which is part of this new toolbox. ThaenaBiotic is a stool-derived postbiotic – essentially a purified collection of the good stuff from healthy donor microbiomes (metabolites, inactivated microbes, and cell components) that can be taken in a capsule. The idea is to provide the gut with the missing signals of a healthy microbiome, without needing to transplant live bacteria. It’s like seeding a garden with nutrients and mulch, rather than dumping weeds killer everywhere. While ThaenaBiotic is just one example, it represents a paradigm shift: using the microbiome’s own language (chemical signals) to heal, rather than simply trying to carpet-bomb the microbes.

Going forward, I envision SIBO treatment plans that might look like:

• Initial reduction of overgrowth (yes, we still need to clear out the excess – maybe with gentler herbals or targeted antibiotics, or even diet therapy).
  
  

• Re-seeding and feeding the gut with the right components – perhaps specific probiotics for certain patients, prebiotics (fibers or polyphenols that feed beneficial microbes), and postbiotics to directly restore metabolic functions. If analysis shows a patient is low in butyrate and high in inflammatory bile acids, we tailor nutrients and supplements to correct that.
  
  

• Repairing the gut environment: focus on the host side – e.g. using nutrients like glutamine or colostrum to support the mucosal lining, stress-reduction techniques to normalize cortisol and the gut-brain axis, and addressing any other “pie slices” like mast cell activation (sometimes using antihistamines or supplements like quercetin) or enzyme insufficiencies (digestive enzyme supplements, bile support).
  
  

• Long-term maintenance: rather than multiple antibiotic rounds, patients may go on a maintenance regimen that could include a prokinetic (to keep motility up), a healthy diet that they can actually live with (not a super restrictive one forever, but balanced with fermentable fibers in moderation), and possibly cyclical use of supportive supplements or postbiotics. The goal is resilience – giving the patient’s gut the ability to stay balanced on its own eventually.
  
  

This holistic, function-focused approach gives me a lot of hope. It means even for those who have failed standard SIBO treatments, there are new angles to try. It also means we might prevent SIBO in the first place by fortifying patients who are at risk (for instance, someone on long-term acid blockers or who has had intestinal surgery could proactively get support to prevent bacterial overgrowth).

In closing, the story of SIBO – from obscure idea to common diagnosis, from one-size-fits-all treatments to personalized, ecosystem-based care – highlights the evolution of medicine itself. We started with the excitement of a discovery that “bugs can cause IBS!” which gave relief to many. We encountered humbling setbacks that taught us the complexity of human biology. And now we stand at the frontier of a new era where microbiome science is guiding us to more nuanced solutions. For the millions of people suffering from chronic GI issues, this evolution is a reason to be optimistic. It’s a sign that we’re inching closer to true root-cause resolution, armed with both high-tech innovations and age-old holistic wisdom.

As a doctor (and a self-proclaimed gut nerd), I find this progress invigorating. I often told my complex GI patients: “You are not a lost cause – we just need to keep searching for the right key to unlock your healing.” With SIBO, that key was discovering a bacterial overgrowth. With today’s advances, the key might be a targeted postbiotic, prebiotics, and a trauma-informed therapy or something we’ve yet to imagine. We’re learning that the gut, much like a garden, will flourish when we care for the soil, not just pull the weeds. And that philosophy – cultivating balance – is where the future of gut health lies.

References:

1. Taylor, M. (2023). SIBO or IBS: Finding the True Cause of your Gut Symptoms. Neighborhood Naturopathic Blog. (Up to 75% of IBS patients may have SIBO and basic SIBO explanation).
   

2. Kashyap, P.C. et al. (2024). An updated appraisal of the SIBO hypothesis and the limits of breath testing. Mayo Clinic Proceedings (notes the hypothesis remains unproven and breath test limitations).

3. Min, Y.W. et al. (2022). Bile Acid and Gut Microbiota in IBS. J Neurogastroenterol Motil. (Bile acids’ role in motility and gut sensitivity, microbiota interactions).