Background Small intestinal bacterial overgrowth (SIBO) is a condition that is defined by an overgrowth of normal flora in the small intestinal, causing symptoms similar to irritable bowel disease, such as abdominal pain, diarrhea, and frequent stools. Altered flora can arise from dysmotility, altered anatomy, such as surgery, or hypochlorhydria. A known condition that is associated with SIBO is auto-brewery syndrome, in that the intestinal flora metabolize carbohydrates into ethanol, which will, then, intoxicate the patient. However, alcohol abuse is a common condition worldwide. Patients that are addicted to alcohol often have financial, social, and interpersonal strain, and those patients often go to great lengths to hide their alcohol abuse to their spouses and family, often involving elaborate lies and trickery. Moreover, a patient that has a history of alcohol abuse is at greater risk of relapse following abstinence from alcohol. Case Presentation We present a case of a 48-year-old patient with a medical history of SIBO who is presenting to the emergency department acutely intoxicated. The patient is accompanied by his wife. She states that since he has been diagnosed with SIBO, he often experiences multiple “episodes” per month where he appears intoxicated, and that it is controlled by a specific diet that they have worked to develop. She endorses that he has a history of alcohol abuse, and that he has abstained from alcohol for about 2 years, with no possibility of the patient relapsing as they both work from home and the majority of their time together. Labs were significant for a blood alcohol level (BAC) of 0.47. He was then admitted to the hospital, and his BAC was trended, which showed a linear decrease of .02 per hour. The patient was not restricted in his diet and was seen to eat carbohydrates, with no increase in BAC, thus ruling out auto-brewery syndrome, leaving a relapse of alcohol abuse as his final diagnosis. Discussion This case provides an intricate display of SIBO, auto-brewery, and chronic alcohol abuse disorder. The endogenous production of ethanol by intestinal microorganisms results in intoxication symptoms. The differentiation of auto-brewery and alcohol use is crucial as management includes carbohydrate-restricted diet, antibiotics, and cessation of alcohol consumption. Psychosocial elements of this case highlight the interdepartmental teamwork from medical doctors, nutritionists, and psychosocial personnel and support systems.