Why Does SIBO Keep Coming Back After Treatment? — Patterns I see in cases of recurrent SIBO

Across the cases I have worked, certain patterns appear consistently. Recurrent SIBO patients tend to share most of the following: A prior infection or significant antibiotic course preceding the first SIBO episode, often by 6 to 18 months. The infection or antibiotic depleted the obligate anaerobic core community, which never fully recovered, and the recurrent SIBO is the readout. A history of NSAID use, alcohol use, or other mucosal-permeability drivers preceding the first episode. These are the inflammatory drivers that initiate SLC5A8 silencing. Concurrent or sequential MCAS, POTS, fatigue, or post-exertional malaise. These are the systemic expressions of the same CD38 induction that compromises the gut substrate, expressed in mast cells, autonomic regulation, and skeletal muscle. Inconsistent response to high-dose butyrate supplementation. This is the SLC5A8 signature. Response to elemental diet that does not hold once normal eating resumes. The elemental diet starves the overgrowth temporarily but does not restore the substrate. A pattern of worsening response with each successive antimicrobial round. This is the cumulative damage to the substrate that each treatment cycle leaves untouched. Normal or near-normal conventional gastroenterology workup. The lesion is functional and cellular. Standard imaging and standard biopsy do not see it. A sense from the patient that the