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A growing number of studies seem to suggest that small intestinal bacterial overgrowth (SIBO) is a common clinical problem. Although various techniques are available to make this diagnosis, tradition has accepted small bowel aspirate (>105 cfu/ml) as a gold standard. In this systematic review, the validity of culture and other diagnostic testing for SIBO is evaluated.We performed a systematic review of the literature from 1966 to present using electronic databases (PubMed and OVID). Full paper review of those abstracts that fulfilled preset criteria was carried out to evaluate the validity of various tests in diagnosing SIBO. Finally, all papers were evaluated against published standards for studies on diagnostic testing.Seventy-one papers met the criteria for detailed review. Studies were very heterogeneous with regards to patient populations, test definitions, sample size, and methods in general. Small bowel colony counts appeared elevated in most gastrointestinal diseases compared to controls. The traditional definition of > 105 cfu/ml was usually indicative of stagnant loop conditions. Although, numerous diagnostic tests were studied, not even culture papers met the quality standards described by Reid et al. Breath testing and other diagnostic testing suffered therefore from the lack of a gold standard against which to validate in addition to the poor quality.There is no validated diagnostic test or gold standard for SIBO. In this context, the most practical method to evaluate SIBO in studies at this time would be a test, treat, and outcome technique.