Table of Content

Defining Small Intestinal Bacterial Overgrowth (SIBO) →
Why SIBO Happens: Uncovering the Underlying Mechanisms (“root cause”) and Contributors →
SIBO Symptoms: Recognizing the Clinical Presentation of Bacterial Overgrowth →
The SIBO – IMO Diagnostic Journey: Understanding Breath Tests and Clinical Realities →
Clinical Protocols for SIBO – IMO Eradication: A Registered Dietitian Perspective on Lasting Recovery →

Preface

Target Audience and Clinical Objective

This article is curated for medical practitioners and gastroenterologists to facilitate evidence-based clinical decision-making.

By synthesizing recent diagnostic validations and international consensus papers, this resource aims to bridge the gap between emerging research and bedside practice, ultimately optimizing patient outcomes and reducing diagnostic delays in the management of SIBO (Small Intestinal Bacterial Overgrowth) and IMO (Intestinal Methanogen Overgrowth).

Clinical Insights from experience:

“Over years of consulting in private practice, I have specialized in gastrointestinal health, supported by extensive continuing education across Europe and North America and rigorous literature reviews.

My experience with Small Intestinal Bacterial Overgrowth (SIBO) has been both frustrating and fascinating.

Frustrating because, despite its significant impact on quality of life, SIBO remains underrecognized and misunderstood.
Yet fascinating because, when properly diagnosed and treated, outcomes can be transformative.

I believe there is an urgent need to standardize how we identify and manage this condition.

SIBO also carries a “bad reputation” due to symptom overlap with other conditions. While abdominal distention (the “pregnant belly”) is often assumed to indicate SIBO, accurate diagnosis requires careful differential assessment to avoid unnecessary antibiotic use “

Defining Small Intestinal Bacterial Overgrowth (SIBO)

Small intestinal overgrowth (SIBO) is clinically defined as the presence of an abnormal bacterial load/dysbiosis in the small intestine (1).
Unlike infections caused by a single pathogen, such as H. pylori, SIBO represents a quantitative shift in the commensal gut microbiota (Non-pathogenic microorganism).

Specifically, we see an overgrowth of Klebsiella and Escherichia coli (2), species usually resident in the colon VS the small intestine (3). These strains are directly linked to the severity of bloating, pain, and diarrhea (2) . Altough, contrarly of what was tought before, it is NOT the bacteria of colon moving in the small intestine like tought before (2)

Under normal physiological conditions, bacterial density in the upper small intestine is strictly regulated by the antimicrobial effects of gastric acid and the mechanical clearing action of peristalsis (1).
In SIBO, however, these physiological defenses become compromised; consequently, bacterial colonization exceeds physiological norms, directly driving the development of digestive distress (3).

Crucially, SIBO must be understood not as a primary disease, but as a secondary consequence of an underlying dysfunction. It is a clinical manifestation of a deeper physiological or mechanical failure.
Consequently, any treatment that focuses solely on eradicating the bacteria overgrowth will fail in the long term; the overgrowth will inevitably return as long as the primary physiological problem (“root cause”) remains unaddressed.

Later, we will differentiate SIBO from distinct entities like IMO (Intestinal Methanogen Overgrowth) and ISO (Intestinal sulfide overproduction). Although these conditions present with overlapping symptoms and diagnostic pathways, they are clinically unique.
Identifying their specific gas production profiles is essential for tailoring therapeutic interventions and ensuring successufl patient recovery.

Why SIBO Happens: Uncovering the Underlying Mechanisms (“root cause”) and Contributors

Physiological Defenses Against Bacterial Overgrowth

SIBO occurs following the failure of the physiological mechanisms that normally maintain low microbial density in the small bowel (1) (3). These critical barriers act as essential defenses against abnormal bacterial expansion (1).

Examples of these protective barriers include:

Gastric acid and bile salts
Intestinal peristalsis (Migrating Motor Complex)
Pancreatic proteolytic enzymes
A functional ileocecal valve
Mucosal secretory IgA (sIgA)

Conditions associated with SIBO (3)

Category	Conditions
Mechanical issues:	– Small bowel tumor – Volvulus – Post-surgical causes (Ex: Gastric bypass, bowel resections, impaired ileocecal valve, adhesions..)
Systemic disease:	– Diabetes – Sclerodermia – Amyloidosis – Hypothyroidism
Medication:	– Opiates – Chronic uses of antisecretory agent: Ex: Proton Pump Inhibitors (PPIs): Omeprazole, Esomeprazole (Nexium), Lansoprazole, Pantoprazole.. (1)
Anatomical:	-Small bowel diverticuloisis
Malabsortive conditions:	– Pancreatic insufficiency – Cirrhosis – Etc
Others:	– Aging – Irritable Bowel syndrome (60% of the IBS-D could have it (5)) – Post-Infectious: History of viral gastroenteritis – Gastroparesis and generalized nerve damage – Celiac disease, Crohn’s disease (1) – Endometriosis (4)

SIBO Symptoms: Recognizing the Clinical Presentation of Bacterial Overgrowth

General symptoms (3)

Pain in the stomach, especially after eating
Bloating and abdominal distention
Cramps
Diarrhea and/ or constipation
Regular feeling of fullness – Early satiety
Excess gas: flatulence, eructation.

Beyond digestive distress, patients frequently report systemic manifestations such as chronic fatigue, impaired concentration, often referred to as “brain fog“ (3)

Patients with severe SIBO can present with low Vitamin B12 but stable or high folate. The drop in B12 is largely due to the destruction of binding sites within the ileum, caused by localized mucosal damage from bacterial overgrowth (1) (3)

Note on IMO and ISO :

The symptomatology of IMO (Intestinal Methanogen Overgrowth) and ISO (Intestinal Sulfide Overproduction) is distinct, primarily driven by the metabolic effects of their respective gases on intestinal transit.

Intestinal Methanogen Overgrowth (IMO) is characterized by excessive methane (CH4) production, which is strongly correlated with delayed transit and chronic constipation (6).

Conversely, Intestinal Sulfide Overproduction (ISO) is associated with elevated hydrogen sulfide (H2S), which typically manifests as increased urgency and diarrhea (11)

Clinical observations from practice:

While less documented in current scientific literature, my clinical experience reveals that many patients also report joint pain and acid reflux. The reflux, in particular, is likely a secondary mechanical consequence of severe abdominal distention, which increases intra-abdominal pressure and displaces the lower esophageal sphincter.

Clinical management should prioritize investigating the underlying etiology of reflux rather than defaulting to the long-term prescription of Proton Pump Inhibitors (PPIs).

The SIBO – IMO Diagnostic Journey: Understanding Breath Tests and Clinical Realities

In the absence of a validated diagnostic gold standard, SIBO is usually identified via breath tests or jejunal aspirates (1). Both have Pros and Cons.

Jejunal aspiration:
Despite its validated diagnostic threshold of >10^3 CFU/mL, jejunal aspiration is rarely utilized due to its invasiveness.
Breath test:
The theory behind breath testing is that human cells do not produce hydrogen (H2) or methane (CH-4) gases.
Their presence in a breath sample is a then a sign of microbial fermentation in the gut. When bacteria break down carbohydrates, they release these gases, which are absorbed into the bloodstream and exhaled through the lungs. This allows for a simple, non-invasive way to measure what is happening inside the small intestine. (3)

The American College of Gastroenterology recommends 75g of glucose or 10g of lactulose, with a cup (250ml) of water (3).
They consider that a rise in hydrogen concentrations of >20 ppm from baseline, within a specific window to avoid capturing colonic fermentation, is considered diagnostic for SIBO.

On the other hand, the presence of methane concentrations >10 ppm at any point during the test is diagnostic of Intestinal Methanogen Overgrowth (IMO) (3).

It is not uncommon for patients to test positive for both hydrogen-producing bacteria and methane-producing archaea simultaneously, a finding that typically warrants a more complex treatment approach.

Note:

Rigorous preparation is essential prior to a breath test to prevent false positives or negatives. This includes a specific preparatory diet and the strict avoidance of certain supplements and medications (when possible) for at least two weeks before the procedure. Those should not be attempted without supervision.
Also, a Low-Fodmap Diet should NOT be followed before a breath-test.

Are breath tests for SIBO reliable ?

Scientific Validation of Lactulose Hydrogen Breath Testing (LHBT) (recent data from 2025)

Microbial Validation: Breath testing has been validated against small bowel culture and sequencing. Hydrogen levels detected on the test correlate with both patient-reported gas symptoms and the metabolic activity of the small bowel microbiota (7).

Transit Differentiation: Using scintigraphy, research confirms that intestinal transit time does not explain a positive breath test. A hydrogen peak of > 20 ppm before the 80-minute mark is a valid indicator of SIBO, allowing clinicians to effectively sub-divide IBS patients into SIBO and non-SIBO phenotypes (8).

Debates between Glucose or lactulose testing:

Dr. Mark Pimentel, a preeminent researcher in the field, advocates for the use of lactulose as the preferred substrate for breath testing. His rationale centers on the fact that glucose is rapidly absorbed in the proximal duodenum, making it ineffective for detecting overgrowth in the more distal segments of the small intestine (the ileum).

Also, the Brazilian Federation of Gastroenterology has recently issued a position paper reinforcing LHBT as a core diagnostic tool. While recognizing the inherent potential for false positives/negatives, the Federation emphasizes that standardizing SIBO diagnosis and treatment is essential to reduce diagnostic delays and optimize patient care (10)

Per the American college of Gastroenterology guidelines, breath testing with glucose or lactulose is recommended for diagnosing SIBO/IMO in symptomatic patients though these are conditional recommendations based on a low level of evidence, as it is all there is available so far (3)

While the European consensus and the Asian-Pacific guidelines both acknowledge breath testing as a necessary interim tool pending a validated gold standard, they favor glucose over lactulose due to its superior specificity (9).
To mitigate diagnostic errors and false positives caused by premature colonic fermentation, the European guidelines suggest that, where feasible, breath tests should be performed alongside simultaneous scintigraphy to accurately monitor orocecal transit (9)

It is important to note that these recommendations preceded more recent evidence discussed above, which demonstrates that rapid intestinal transit does not necessarily explain a positive breath test, as many early hydrogen peaks occur while the substrate is still definitively within the small bowel.

Note: Glucose VS Lactulose (3)

Sensitivity: The test’s ability to correctly identify those with SIBO (avoiding false negatives)
Specificity: The test’s ability to correctly identify those without SIBO (avoiding false positives)

Lactulose:
– Sensitivity: 31% – 68%
– Specificity: 44% – 100%
– Not absorbed by humans; reaches the colon in all patients. Fast transit can potentially cause early colonic fermentation, leading to false-positive SIBO results.
Glucose
– Sensitivity: 20% – 93% (depends where the SIBO is in the intestines)
– Specificity: 30% – 86%
– Rapidly absorbed in the proximal (upper) small intestine –> Risk of false negatives (Never reaches bacteria in the distal (lower) small bowel).

The “Hydrogen Sink”: Clinical Necessity of Multi-Gas Testing

Measuring hydrogen (H2) in isolation carries a high risk of false-negative results. This is due to the “hydrogen sink” effect, where H2 is consumed as a substrate by secondary microbes to produce Methane (CH4) and/or Hydrogen Sulfide (H2S).

Clinical Recommendation: As noted by Dr. Mark Pimentel (Microbiome 360°, 2025), breath testing should include CH4 at a minimum. Triple-gas testing (e.g., TrioSmart) is the preferred gold standard; despite the higher cost, it is the only validated method to detect H2S and prevent missed diagnoses.

Clinical Perspective from my practice concerning the utilisation of breath tests and SIBO Diagnosis

The Risks of Direct-to-Consumer Testing

As breath tests have become increasingly accessible to the public, there is a concerning rise in self-diagnosis and unsupervised management provided by non-accredited individuals, which lacks the clinical rigor necessary for safe and effective treatment.
Due to the risk of false-positive results, it is imperative that neither clinicians nor patients jump to conclusions based on a lab report alone. Independent testing and self-administration of “natural herbal antimicrobials” bypass the essential clinical evaluation required to differentiate SIBO from other functional gut disorders; this lack of professional oversight risks exacerbating underlying pathologies and further compromising intestinal homeostasis.

The Consequences of “The Positive Test”

A positive SIBO result typically leads to one or more courses of antibiotics. In an era of rising antimicrobial resistance, adverse drug reactions, and the increased incidence of opportunistic infections like Clostridium difficile, we must adopt a more cautious diagnostic threshold.
Antibiotic therapy should only be considered after an objective, medically supervised diagnosis is confirmed and baseline interventions have been exhausted (2).

The GI Dietitian as the Frontline Specialist

In my practice, a significant number of referrals/reasons of consultation for suspected SIBO are successfully resolved through targeted dietary and lifestyle interventions (which means it was not SIBO/IMO afterall, as dietary interventions alone CANNOT clear a SIBO/IMO/ISO).
This completely removes the need for pharmacological treatment.

Gastroenterology-specialized Registered Dietitians should serve as the primary point of contact; remarkably, clinical symptoms often resolve simply by addressing underlying mechanics and behavioral factors, frequently bypassing the need for restrictive interventions like the Low FODMAP diet.

Exemple: chronic clinical “distention” is always what brings people to think they have a SIBO.
Other reasons for distention that I see everyday:

Constipation: A patient may have daily bowel movements but remain profoundly constipated due to incomplete evacuation.
Fiber Imbalance: Too much insoluble fiber or a lack of total/soluble fiber.
Energy Distribution: A poor distribution of energy (caloric intake) throughout the day.
Feeding Mechanics: Eating too fast, in a rush, or while stressed.
Digestion Basics: Not chewing enough or not breathing properly.
And so much more more.

Addressing these issues often resolves the “SIBO symptoms” without the need for a single pill.

The Hierarchy of Care

Testing and treatment should not be a reflexive prescription of antibiotics for every symptomatic patient; instead, our clinical approach should follow a structured progression:

Thorough Evaluation:
Comprehensive analysis of mental state, symptoms, motility, nutritional habit, and risk potentials differentials diagnosis (Including referrals if indicated)
Nutritional Intervention:
Monitoring the impact of dietary and lifestyle changes.
Targeted Testing:
Reserving breath tests only for those who remain in significant distress despite foundational nutritional/habits improvements.
Evidence-Based Treatment:
Considering antimicrobial therapy (By referral to patient’s doctor) only when a confirmed positive test (interpreted by a qualified health professional) aligns with persistent, non-responsive clinical symptoms

Clinical Protocols for SIBO – IMO Eradication:

A Registered Dietitian Perspective on Lasting Recovery

1. Therapeutic Overview: SIBO – IMO :

The ACG guidelines suggest utilizing antibiotic therapy for symptomatic SIBO patients with the dual goals of eradicating microbial overgrowth and achieving symptom resolution (3)

Therapeutic strategies for SIBO-IMO are tailored to the specific gases identified during breath testing.

While hydrogen-dominant overgrowth typically responds well to a single antibiotic, the presence of methane, whether alone or alongside hydrogen, often necessitates a combination of antibiotics, as Rifaximin monotherapy is frequently insufficient.
In many clinical cases, one to three treatment cycles may be required to achieve full symptomatic relief (1)

For Hydrogen-Dominant SIBO (Small Intestinal Bacterial Overgrowth), the first-line treatment is usually Rifaximin administered for 14 days (12)
Due to its minimal systemic absorption, rifaximin acts locally in the gut, significantly reducing the risk of adverse systemic effects. Its favorable safety profile and clinical effectiveness are well-supported by a robust body of research.

For Intestinal Methanogen Overgrowth (IMO), patients testing positive for methane-producing organisms require a more aggressive dual-therapy approach to penetrate the archaeal cell wall.
The recommended protocol is a 14-day combination therapy, usually a combination of Neomycin: 500 mg, twice daily (BID) OR Metrodinazole TID (250mg) (2) and Rifaximin: 550 mg, three times daily (TID) (12)

For ISO, the treatment protocol is distinct; while combinations of bismuth and rifaximin are currently being investigated, further research is required to establish a definitive therapeutic standard (11)

Diet during the “Kill Phase” Protocol:

During the active 14-day antimicrobial treatment, patients should not attempt specific restrictive diets, such as Low FODMAP or Gluten-Free. Clinical logic suggests that bacteria are more vulnerable to antibiotics when they are active and replicating. Restricting fermentable carbohydrates during this phase can cause the bacteria to go into a “dormant” or “hibernating” state, potentially reducing the efficacy of medications like Rifaximin.

Clinical Perspective from my practice:

In clinical practice, a frequent observation in the field is the use of ‘blind’ antibiotics prescriptions by some practitioners, before confirming a SIBO/IMO diagnosis.

This approach fails to account for the quantity and type of gases present, such as methane, which requires specific combination therapy.

It also fails to consider that these symptoms overlap significantly with other conditions, or nutritional habits, and that a blind course of antibiotics skips many less invasive, lower-risk interventions that could have resolved the symtpoms.

It is impossible to definitively diagnose SIBO based solely on a patient’s symptoms without first attempting nutritional and mechanical interventions.

The common justification that “breath tests are unreliable” ignores a fundamental clinical truth: having objective data, provided that false results are minimized through the preparatory steps discussed above, remains far superior to diagnostic guesswork.

Consequently, a referral to a specilized Registered Dietitian should be the priority before reaching for a prescription, especially a “blind” one.

While patients may report an initial reduction in symptoms, the underlying overgrowth often persists, frequently because :

The initial gas levels were too high for a single round
The incorrect antibiotics were used for that specific gas profile.

Are there other ways to treat SIBO – IMO than using antibios?

While dietary modifications alone do not eradicate SIBO – IMO, the elemental diet serves as a potent alternative for patients who cannot tolerate or fail to respond to multiple courses of antibiotics.

Although limited by high costs and poor palatability, observational data show that 80% of patients achieved full remission, defined by both symptom resolution and normalized breath tests, within 14 days (13).

Caution:

The implementation of an elemental diet should never be attempted without a confirmed SIBO diagnosis and strict professional guidance.
Because of its restrictive nature and specific nutritional profile, supervision is mandatory to ensure patient safety and therapeutic success.

2. Preventing SIBO Recurrence:

Identifying the Primary Drivers of Clinical Relapse

According to the American College of Gastroenterology, a study of 80 adults treated with antibiotics demonstrated significant relapse rates over time: 12.6% at three months, 27.5% at six months, and 43.7% at nine months. These findings suggest that for nearly half of patients, antimicrobial therapy alone is insufficient for long-term resolution (2)

Nutritional support:

To ensure long-term success, dietary management must transition to an individualized, symptom-based strategy. This personalized nutritional work focuses on supporting the Migrating Motor Complex (MMC), managing specific food intolerances, and restoring microbiome diversity.

Monitoring for “Early Warning” Signs
Why Treatment is Mandatory: Beyond the Symptoms

SIBO is not an isolated gut disorder; it is a contributor to liver-related pathologies and is commonly linked with renal and pancreatic diseases (1). A thorough investigation into its primary drivers (“root cause”) is mandatory to prevent the severe weight loss and nutritional depletion associated with chronic cases. Early diagnosis is the primary defense against the progression toward intestinal failure and associated mortality (1)

Why is starting with a GI dietitian a good start?

To improve patient outcomes and alleviate the burden on physician and gastroenterologist waitlists, this model ensures that specialized medical resources are reserved for the most complex cases.

In many healthcare systems, like Quebec’s, the wait for a gastroenterologist is notoriously long.
During that gap, a GI dietitian can analyze the nuances of a patient’s reactions to food and lifestyle habits to determine if a clinical diagnosis like SIBO is even necessary.
This partnership allows for a more efficient diagnostic path, where simpler issues are resolved through diet, and complex cases are better prepared for the specialist when the appointment finally arrives.

Conclusion:

Small intestinal bacterial overgrowth (SIBO) and IMO are high-stakes conditions that require a coordinated, multidisciplinary effort for successful management.

Timely recognition is the primary defense against malnutrition, systemic complications, and a significantly impaired quality of life.

In clinical practice, the impact is profound; many patients seeking GI support are on extended sick leave, unable to maintain their professional or social lives due to debilitating symptoms.

Once a diagnosis is confirmed and treatment begins, the clinical focus must pivot: we must investigate and address the underlying “why”.

Sustainable recovery, and a successful return to work and daily function, is only possible when we treat both the overgrowth itself and the physiological factors that allowed it to manifest in the first place.

What now ?

Many symptoms may point toward SIBO
But a wide range of gastrointestinal and mechanical issues can mimic its presentation.
Distinguishing between true overgrowth and these “mimics” is essential for effective treatment.

Please consult a qualified health professional to ensure an accurate diagnosis and to explore the most appropriate therapeutic options.

A specialized practitioner can help you navigate this process
while ensuring long-term nutritional adequacy and symptom resolution.

Book a consultation

References:

Sorathia, S. J., Chippa, V., & Rivas, J. M. (2023). Small Intestinal Bacterial Overgrowth. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK546634/
Leite, G., Rezaie, A., Mathur, R., Barlow, G. M., Rashid, M., Hosseini, A., Wang, J., Parodi, G., Villanueva-Millan, M. J., Sanchez, M., Morales, W., Weitsman, S., Pimentel, M., & REIMAGINE Study Group (2024). Defining Small Intestinal Bacterial Overgrowth by Culture and High Throughput Sequencing. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, 22(2), 259–270. https://doi.org/10.1016/j.cgh.2023.06.001
Pimentel, M., Saad, R. J., Long, M. D., & Rao, S. S. C. (2020). ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth. The American journal of gastroenterology, 115(2), 165–178. https://doi.org/10.14309/ajg.0000000000000501
Singh, S., Verma, N., & Taneja, N. (2019). The human gut resistome: Current concepts & future prospects. Indian Journal of Medical Research, 150(4), 345–358. https://doi.org/10.4103/ijmr.IJMR_1979_17
Ghoshal, U. C., Sachdeva, S., Pratap, N., Karyampudi, A., Mustafa, U., Abraham, P., Bhatt, C. B., Chakravartty, K., Chaudhuri, S., Goyal, O., Makharia, G. K., Panigrahi, M. K., Parida, P. K., Patwari, S., Sainani, R., Sadasivan, S., Srinivas, M., Upadhyay, R., & Venkataraman, J. (2023). Indian consensus statements on irritable bowel syndrome in adults: A guideline by the Indian Neurogastroenterology and Motility Association and jointly supported by the Indian Society of Gastroenterology. Indian Journal of Gastroenterology, 42, 249–273. https://doi.org/10.1007/s12664-022-01333-5
Mehravar, S., Takakura, W., Wang, J., Pimentel, M., Nasser, J., & Rezaie, A. (2025). Symptom Profile of Patients With Intestinal Methanogen Overgrowth: A Systematic Review and Meta-analysis. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, 23(7), 1111–1122.e9. https://doi.org/10.1016/j.cgh.2024.07.020
Leite, G., Morales, W., Weitsman, S., Celly, S., Parodi, G., Mathur, R., Barlow, G. M., Sedighi, R., Millan, M. J. V., Rezaie, A., & Pimentel, M. (2020). The duodenal microbiome is altered in small intestinal bacterial overgrowth. PloS one, 15(7), e0234906. https://doi.org/10.1371/journal.pone.0234906
Dahlgren, A., Grybäck, P., Jacobsson, H., & Hellström, P. M. (2025). Refined Lactulose Hydrogen Breath Test for Small Intestinal Bacterial Overgrowth Subgrouping Irritable Bowel Syndrome With Low and High Breath Hydrogen. Gastroenterology research and practice, 2025, 5597071. https://doi.org/10.1155/grp/5597071
Kashyap, P., Moayyedi, P., Quigley, E. M. M., Simren, M., & Vanner, S. (2024). Critical appraisal of the SIBO hypothesis and breath testing: A clinical practice update endorsed by the European society of neurogastroenterology and motility (ESNM) and the American neurogastroenterology and motility society (ANMS). Neurogastroenterology and motility, 36(6), e14817. https://doi.org/10.1111/nmo.14817
Quigley, E. M. M., Bazzoli, F., Boeckxstaens, G., Chen, M. S., Cohen, H., Dominguez-Muñoz, J. E., … & Lembo, A. (2024). Position paper from the Brazilian Federation of Gastroenterology on the diagnosis and treatment of small intestinal bacterial overgrowth (SIBO). Arquivos de Gastroenterologia, 61, e20240107. https://doi.org/10.1590/S0004-2803.24612024-107
Pimentel, M. (2025). Actualités sur le SIBO, l’IMO et l’ISO. Presented at the Formation Microbiome 360°, 1ère édition
Quigley, E. M. M. (2024). Small intestinal bacterial overgrowth: Management. UpToDate. Retrieved 3/02/2026, from https://www.uptodate.com/contents/small-intestinal-bacterial-overgrowth-management
Pimentel, M., Constantino, T., Kong, Y., Bajwa, M., Rezaei, A., & Park, S. (2004). A 14-day elemental diet is highly effective in normalizing the lactulose breath test. Digestive diseases and sciences, 49(1), 73–77. https://doi.org/10.1023/b:ddas.0000011605.43979.e1