T2 or NAFLD? ...or, a funny thing happened on the way to the surgery

Chris24Main

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I do wonder if I actually have insulin resistance though or just a deficit of insulin. God knows why I'd have become resistant to it, none of the explanations really make sense for me.
This kind of hits the nail on the head, and I guess describes the way that many of us feel, and also gets to why it's so difficult to persuade anyone without a diagnosis that they may want to pay attention to insulin - surely I'm ok?

And, one level underneath that is the problem that diabetes focuses on the blood glucose - all the diagnostic measurements, all the guidelines, all the advice, all the drugs - it's all about controlling blood glucose..

To the point that as a newly diagnosed patient (at least for me) it's terribly difficult even to understand the difference between T1 and T2 -

When you see them as issues with hormone balance, they are clearly opposites: T1 too little insulin and T2, too much.

Then - why would I be resistant to it?
Well, that becomes a little easier to understand - why does anyone become resistant to anything - by having too much of it.
Coffee, alcohol, stress, People crying Wolf, exercise, heroin, anything that has an effect on you, that effect will reduce if you trigger the effect too often.

It's ridiculously more complicated at the cellular and organ levels, but at the person level - "too much of a good thing" is all you really need to know.

Everybody is insulin resistant for a period, for example - it's called puberty, but you literally cannot grow enough without most of your body becoming resistant to the demands of insulin during the period where the bits of your body that need to grow, do...
 
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Chris24Main

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@RachelG. - can I ask which type of body comp scales? - I only ask because I have a Withings model, so my visceral fat score may be completely different to yours, but that's one of the key metrics for me.. I can't help but know the overall weight, but I'm more interested in making sure my muscle mass stays up, and basically, I fast whenever my visceral fat hits a threshold. for me that's 3.8 - but as I say, it may have no relevance to the score you have. In any case, I think trends are more useful than absolute numbers...

... I've tripped up mentioning this before, but there is also the simple fact that men and women have an evolutionary need to store fat differently. There are lots of insensitive ways to put it, but maybe the safest is that men will never need to reserve space for a baby, so they will fill up that space with fat more easily. that - Visceral fat - is different to fat stored elsewhere, because the cells are stuffed full, rather than becoming more cells .. which means stretched and inflamed. It's why visceral fat is a key part of the set of markers for metabolic syndrome (which used to be called insulin resistant syndrome).
 

RachelG.

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So, @RachelG. I do not produce enough insulin and my C-peptides are low normal so I‘m thinking that I do not have an insulin resistance problem, else I would be producing a lot more insulin, and correspondingly, my C- peptides would be higher. I keep my blood sugars in check with work outs. I do around 25,000 - 30,000 steps a day, plus resistance training. I’ve had some high night time blood sugar readings recently, not sure why. Yes TOFI is a thing. It depends on where your body decides to store excess fat. In TOFI the fat tends to congregate around your organs and belly region, adding IR into the mix. For sure poor muscle mass can affect your blood sugars , not surprising really as your skeletal muscles use up to 70% of your blood glucose.

I’m going to get my C-peptides checked again as it was a while back I had them tested. If your insulin production is significantly compromised, for what ever reason, then any slight rise in insulin resistance will affect your blood sugars. There are some interesting research papers on ’lean’ diabetes on line.
Thanks - can I ask what tests your doctor did to confirm you don't have insulin resistance but simply don't produce enough insulin? Is it just c peptides or are there other relevant tests?

I am thinking of attacking my problem on 2 fronts - I want to try to reduce my visceral fat/body fat percentage to the lower end of normal in case I am TOFI and also try to persuade my gp to run tests to see if I have an insulin deficient or insulin resistance. I am suspecting the latter but open to either possibility.

One concern I have is that as I come out in body composition scans and also just visibly as above average muscular it skews my BMI slightly so I don't want to lose too much fat and end up within normal range bmi but actually functionally underweight. Hence the need to try to see how much of my weight is fat/muscle/bone etc.
 

RachelG.

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@RachelG. - can I ask which type of body comp scales? - I only ask because I have a Withings model, so my visceral fat score may be completely different to yours, but that's one of the key metrics for me.. I can't help but know the overall weight, but I'm more interested in making sure my muscle mass stays up, and basically, I fast whenever my visceral fat hits a threshold. for me that's 3.8 - but as I say, it may have no relevance to the score you have. In any case, I think trends are more useful than absolute numbers...

... I've tripped up mentioning this before, but there is also the simple fact that men and women have an evolutionary need to store fat differently. There are lots of insensitive ways to put it, but maybe the safest is that men will never need to reserve space for a baby, so they will fill up that space with fat more easily. that - Visceral fat - is different to fat stored elsewhere, because the cells are stuffed full, rather than becoming more cells .. which means stretched and inflamed. It's why visceral fat is a key part of the set of markers for metabolic syndrome (which used to be called insulin resistant syndrome).
Hi Chris,

It was Omron BF511, not super expensive so not sure how accurate they are but hopefully reliable enough to see trends. Interesting your limit is 3.8, I will try to reduce mine to that number and see if blood glucose improves.
 

Wilbach

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@Wilbach - sorry for the lack of reply - you understand that nobody on the forum should ever try to diagnose anyone else or suggest changes in medication. This thread in particular has become kind of a safe space for those interested in digging deeper into some of the science, to try to find out if we can learn together - But I have to keep stressing that this is all learning on the go - I certainly do not have any medical credibility, and you should take nothing here as medical advice.

That said - Metformin is an interesting medication. It originated as a natural compound, so the simple truth is that it's effective at lowering blood glucose, and I think most would agree that it does so with the least amount of side effects, but nobody really knows all the ways it affects the body. One of the biggest ways that it does seem to work is by interfering with the process that has the liver break down stored sugars - so that there are less in the blood. That is good from a blood perspective, but my starting point was that I wanted to reduce the fat in my liver, so anything that was going to block it from working as it wanted to may go against my plan...

But - I had been using a CGM for many months at that point, and I was very finely attuned to my blood sugar in different scenarios, and I felt confident that fasting was going to be more effective than Metformin, and I set out to prove it to my GP. In the end my GP was happy, but my situation is not the same as yours.

I understand what you say, I do appreciate that you cannot advise! Metformin originates from the lilac, I am a botanical taxonomist for my sins. Very interested in what you say about Metformin and my situation is very similar to yours. I am stopping Metformin for the same reasons that you have. I am also on very strict keto diet. Do you can see my interest in your explanations. Very much appreciated!
 

Chris24Main

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Oh no - please don't - I have no idea that 3.8 on my machine means 3.8 on yours - that was why I was asking; more than that, I have no idea what the correct value is for anyone... just for me, after I switched to low carb, my scales registered a drop from ~4.5 to ~3.7 and then stayed flat (I was about a month into it before I upgraded the scales, so no idea what the starting number was)..

For me - and noting that my journey started off at more or less ideal overall weight, but clearly eating too much fruit and honey, thus either getting into NAFLD, or exacerbating an existing long-term insulin resistance, then 8 months of taking insulin under a T1 diagnosis. The effect of that was to put on three stone. When I altered my diet, and started intermittent fasting, my weight (all of this fat, muscle raised slightly) dropped away and flatlined on the weight I started out at....

so I took the visceral fat measurement at that point as a baseline ... so whenever it rises, I fast for a day.. typically, my overall weight drops by about 1kg, and most of that goes back on again the following day, but the visceral fat stays down.

I think of this as the "little bucket - big bucket" approach - this is vastly over-simplifying, but particularly if you are eating carbs - you have a small bucket - your liver, and when that's full, you store in your body, big bucket.
Fasting is a way of reversing that - if you fast for more than 24 hours, you empty the little bucket completely..
 

Wilbach

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I understand what you say, I do appreciate that you cannot advise! Metformin originates from the lilac, I am a botanical taxonomist for my sins. Very interested in what you say about Metformin and my situation is very similar to yours. I am stopping Metformin for the same reasons that you have. I am also on very strict keto diet. Do you can see my interest in your explanations. Very much appreciated!

I certainly want to reduce the fat in my liver. With my autoimmune conditions it makes me think I might be LADA 1.5 but I need a c peptide and fasting insulin to a get an idea of what is going on with those beta cells!
 
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Chris24Main

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I understand what you say, I do appreciate that you cannot advise! Metformin originates from the lilac, I am a botanical taxonomist for my sins. Very interested in what you say about Metformin and my situation is very similar to yours. I am stopping Metformin for the same reasons that you have. I am also on very strict keto diet. Do you can see my interest in your explanations. Very much appreciated!
Oh - fantastic - so you have experience from completely the other perspective - so, a botanical taxonomist, does that give you any insight into the use of the lilac as a herbal remedy ?
[again, in that sense of geeks staying behind after class to read the textbook - I don't want to influence anyone re: use of Metformin]

So - My GP had said that Metformin "would reduce insulin resistance" - in some ways my starting point to this was a sense of outrage at the poor use of the double negative.. why would anyone talk about reducing a resistance?

About a month later, armed with all my graphs, firstly I explained that since I was intermittent fasting, I didn't want to take metformin on an empty stomach.

secondly, I explained that since the main purpose of the drug was to throttle the liver, and the resulting drop in blood glucose only made it look like there was a reduction in insulin resistance - the drug itself had no effect on insulin directly. My GP pondered that and eventually said "well, I can see why you would say that" - and we left it there.

But, yes, my intent was to reduce carbs (I wasn't strict Keto then; don't think I could even define what that was at that point) and use fasting every other day to flush out my liver, so that over a month or so I could show that Metformin wasn't necessary - and seek forgiveness rather than approval (again, based on my confidence in knowing what was going on with my glucose levels).

That worked for me, and my GP was happy to hold off on Metformin... but again, that's different to stopping after some time of regular use..
 
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Chris24Main

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I certainly want to reduce the fat in my liver. With my autoimmune conditions it makes me think I might be LADA 1.5 but I need a c peptide and fasting insulin to a get an idea of what is going on with those beta cells!
Yes - absolutely - very good plan...
 
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Wilbach

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Yes - absolutely - very good plan...

I have been using Metformin for years 9+ I almost feel it has no use! Just doing an experiment not taking it to see what the CGM says!
After a day+ see no difference to the levels of glucose! I suspect I have to go down to Dublin to get those tests done straightaway and hit the thing on the head, are my beta cells nackered or have I got plenty of insulin. Horrific that I cannot get these done in Ireland except through a consultant, if he agrees. It is almost like a death sentence, sorry but this does depress me.
Thanks so much for your contributions
William
 

Wilbach

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I have been using Metformin for years 9+ I almost feel it has no use! Just doing an experiment not taking it to see what the CGM says!
After a day+ see no difference to the levels of glucose! I suspect I have to go down to Dublin to get those tests done straightaway and hit the thing on the head, are my beta cells nackered or have I got plenty of insulin. Horrific that I cannot get these done in Ireland except through a consultant, if he agrees. It is almost like a death sentence, sorry but this does depress me.
Thanks so much for your contributions
William

I have been taking it on an empty stomach and managing as I do a 14hr fast every day.
 

Chris24Main

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oh - wow - so it really does sound very similar to me.
So, then, some additional context:
I had just been switched diagnosis - T1 to T2 - on the basis of a C-peptide test. That was the most conclusive thing, and as I think you're completely aware, shows some normal function of the pancreas's ability to make insulin (the C-peptide denoting natural insulin)
Well prior to that, I was questioning my T1 diagnosis; - I was seeing CGM responses that just didn't make any sense unless I was producing some of my own insulin.

Beyond that - my sense was that while Metformin is clearly effective at reducing blood glucose, it does so by stopping the liver from adding to that "problem" - not by addressing the underlying problem, which I saw as too much glucose and insulin in my body - and the way to address that being to start with emptying my liver.

if I did that (and I could do that safely with no hypos, which is what I was mainly worried about, after 9 months thinking like a T1) then Metformin wasn't going to do anything useful anyway - my blood glucose should already be low.

My sense of the whole "are my beta cells knackered" thing is that the period I had with additional insulin gave my pancreas a rest, and allowed it to recover. More broadly, there are clearly ways that the pancreas can be permanently damaged, but I haven't seen any evidence that says an overworked beta cell cannot recover.

It sounds like you are already doing all the right things - knowing what I know now, that C-peptide test was a life saver for me. But - the key difference was that prior to that test, it was assumed I was Type 1 and was prescribed insulin injections accordingly.

Not sure really if any of this helps. I think if you are using a CGM and you are strict Keto - you will see yourself what your blood glucose levels are (you understand that I'm deliberately not saying "you will see whether they are low enough to drop the Metformin") - can I ask what you are seeing?
 

Wilbach

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oh - wow - so it really does sound very similar to me.
So, then, some additional context:
I had just been switched diagnosis - T1 to T2 - on the basis of a C-peptide test. That was the most conclusive thing, and as I think you're completely aware, shows some normal function of the pancreas's ability to make insulin (the C-peptide denoting natural insulin)
Well prior to that, I was questioning my T1 diagnosis; - I was seeing CGM responses that just didn't make any sense unless I was producing some of my own insulin.

Beyond that - my sense was that while Metformin is clearly effective at reducing blood glucose, it does so by stopping the liver from adding to that "problem" - not by addressing the underlying problem, which I saw as too much glucose and insulin in my body - and the way to address that being to start with emptying my liver.

if I did that (and I could do that safely with no hypos, which is what I was mainly worried about, after 9 months thinking like a T1) then Metformin wasn't going to do anything useful anyway - my blood glucose should already be low.

My sense of the whole "are my beta cells knackered" thing is that the period I had with additional insulin gave my pancreas a rest, and allowed it to recover. More broadly, there are clearly ways that the pancreas can be permanently damaged, but I haven't seen any evidence that says an overworked beta cell cannot recover.

It sounds like you are already doing all the right things - knowing what I know now, that C-peptide test was a life saver for me. But - the key difference was that prior to that test, it was assumed I was Type 1 and was prescribed insulin injections accordingly.

Not sure really if any of this helps. I think if you are using a CGM and you are strict Keto - you will see yourself what your blood glucose levels are (you understand that I'm deliberately not saying "you will see whether they are low enough to drop the Metformin") - can I ask what you are seeing?

Will answer shortly, you can see why I was immediately interested in your story, mine slightly different, but your Metformin information very relevant. Much appreciated,
William
 

Melgar

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Thanks - can I ask what tests your doctor did to confirm you don't have insulin resistance but simply don't produce enough insulin? Is it just c peptides or are there other relevant tests?

I am thinking of attacking my problem on 2 fronts - I want to try to reduce my visceral fat/body fat percentage to the lower end of normal in case I am TOFI and also try to persuade my gp to run tests to see if I have an insulin deficient or insulin resistance. I am suspecting the latter but open to either possibility.

One concern I have is that as I come out in body composition scans and also just visibly as above average muscular it skews my BMI slightly so I don't want to lose too much fat and end up within normal range bmi but actually functionally underweight. Hence the need to try to see how much of my weight is fat/muscle/bone etc.
My C-peptide results indicate that my pancreas is not churning out lots of insulin. C-peptides are used to measure insulin production, as there is a correlation between insulin production and c-peptide production. Insulin has a shelf life of just a few hours, whereas C-peptides have a significantly longer shelf life so the labs use C-peptides to assess insulin production.
With Insulin resistance the pancreas has to produce a lot of insulin to counter the body’s resistance to insulin, therefore C-peptide production will be high.

I am lean and very fit. I have a BMI of 19. Unstable blood sugars. I tried the very low carb diet for 9 months, it did little to lower my blood sugars.
 

Chris24Main

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As is so often the case.. it's a little more complicated than that. I was just thinking.. hang on.. insulin doesn't have a shelf life at all.. that sounds like something a doctor would say...

Human, self produced, insulin is made in three parts, an A chain, B chain and a middle C chain which joins the two (chains of amino acids) together. When you finally have what we know as insulin.. the C chain is discarded.. all three amino acid chains are peptides.. so what you have is the C-Peptide being left over, and thus that's what we test for.

As far as I understand it.. there are then other hormones who's job it is to break down insulin.. but thinking in terms of shelf life is unhelpful because it doesn't just happen by itself... you need to understand what it is that degrades the insulin and why. (I forget for the moment.. I'll put it on my list).

I still think that what's underneath everything for you @Melgar is something akin to an overstimulated liver, that keeps pumping out glucose (from protein probably), in gluconeogenesis, under influence of glucagon... something along the lines of an opposite to ketoacidosis, and nowhere near so toxic. You don't eat or have available much fat, but you consume loads of energy, so your liver has no fat to burn and must generate glucose for energy.. but this glucose doesn't impact the pancreas in the same way as dietary glucose, so doesn't trigger corresponding insulin to balance the glucacon, so it just makes more than you really need.

I only really offer that because I've found myself talking about the pancreas as a kind if 'glucose thermostat' a lot recently, but that's only with glucose absorbed via the gut. The liver will just keep on acting under the influence of glucagon (break down fats, break down glycogen, create glucose, suppress insulin) until there is a reason to change.

I even wonder if you might find that (counter intuitively) something sweet might LOWER your blood glucose, by triggering that insulin response, which would then suppress the glucagon..

Bet you didn't expect that...!
 
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RachelG.

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Oh no - please don't - I have no idea that 3.8 on my machine means 3.8 on yours - that was why I was asking; more than that, I have no idea what the correct value is for anyone... just for me, after I switched to low carb, my scales registered a drop from ~4.5 to ~3.7 and then stayed flat (I was about a month into it before I upgraded the scales, so no idea what the starting number was)..

For me - and noting that my journey started off at more or less ideal overall weight, but clearly eating too much fruit and honey, thus either getting into NAFLD, or exacerbating an existing long-term insulin resistance, then 8 months of taking insulin under a T1 diagnosis. The effect of that was to put on three stone. When I altered my diet, and started intermittent fasting, my weight (all of this fat, muscle raised slightly) dropped away and flatlined on the weight I started out at....

so I took the visceral fat measurement at that point as a baseline ... so whenever it rises, I fast for a day.. typically, my overall weight drops by about 1kg, and most of that goes back on again the following day, but the visceral fat stays down.

I think of this as the "little bucket - big bucket" approach - this is vastly over-simplifying, but particularly if you are eating carbs - you have a small bucket - your liver, and when that's full, you store in your body, big bucket.
Fasting is a way of reversing that - if you fast for more than 24 hours, you empty the little bucket completely..

Thanks Chris, if you have a Withings scale then you might be onto something. Mine says 'healthy' is from 1-9 but the Withings one apparently says 0-5 so not possible to compare between. Probably not a bad idea to have as little visceral fat as possible though. I'm a bit cautious about fasting - when I've eaten nothing due to travelling and not finding anything suitable to buy, my CGM recorded a massive spike when I did eat, even though it was a low carb meal. Also I have a bit of a problem fasting on Yom Kippur and fainting (although that could also be lack of water). And my CGM records values lower than 4 in my sleep quite often, even though I sleep on my stomach so I'm not compressing the sensor.
 
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Bcgirl

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I even wonder if you might find that (counter intuitively) something sweet might LOWER your blood glucose, by triggering that insulin response, which would then suppress the glucagon..

Bet you didn't expect that...!

I did this very experiment. I, like Melgar, am not insulin resistant, have a low bmi, exercise, eat so very close to carnivore yet I cannot get my blood sugar below 6….or it’s very rare. My pancreas is very damaged after a bout of severe acute pancreatitis. My A1C is prediabetic. So one day, after three years of zero sugar, decided to eat some ice cream while on a fun road trip. It was my second last day of my CGM so the test would be recorded….and what happened? Well, my blood sugar spiked to above 16 before it rapaidly decreased to below normal levels. I’ll attached the screen shot. It didn’t last too long but I did find it interesting.
IMG_3524.png
 
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Bcgirl

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Another thing, today I had some bloodwork done….fasting glucose, fasting insulin and c peptide. I’m super interested in seeing the difference between the insulin and cpeptide. I shall report back.
 

Melgar

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@Chris24Main I’m referring to insulin being unstable outside the body, it deteriorates within hours and therefore cannot be tested by the lab, unlike C-peptides. That’s my understanding why we test c-peptides and not insulin. C-peptides can last up to 3 weeks with the correct stabilizers.

Interesting, your thoughts on my liver over producing. Would weight gain not be an outcome of an over producing liver? And why wouldn’t I have insulin resistance if there is an excess of energy ? Why do I hypo ? I did have some tests on my liver when they were looking into why I was going low, my liver was working perfectly. That said I’m not sure how that would show up if it wasn’t. I eat a Mediterranean diet so it’s balanced, chicken and fish as my protein. I don’t eat animal fat from meat but I do use a bit of butter and cheese. So my question would be why when I did the very low carb diet, I was eating around 35 grams of carbs per day, at the same time I was doing very physical work and in ketosis, why didnt my blood sugars go down ? Not that we can diagnose, but it’s a pertinent question.

I also have an ongoing issue in my upper right quadrant and mid stomach. I have bouts of serious pain, it’s not indigestion, or gas or GERD it’s something different. The pain is about 8/10 and I have a high pain threshold. It’s the third time I’ve had this bout of serious pain in the last 6 months. The first time I had it, it last for 3 days, the pain was there but it was moderate. It was enough for me to report it to my Dr. The second time I had it, the pain was not as bad and lasted about 24 hours. This time, however, the pain was pretty intense, the worst yet, radiating into my back. My abdomen was too tender to touch. I felt like throwing up. The extreme pain lasts about 4 - 5 hours then it lessoned to a 3-4 /10 the next day. My blood sugars went high for several days. No bilirubin in my pee. No jaundice.

I cannot tolerate fats so Fats are not big in my diet. I’m going make another appointment with my Dr. Something is going on. I lay there wondering whether to call911.
Like @Bcgirl, I am very sensitive to carbs, sweet things send my blood sugars way up and they stay up for several hours !
 
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Antje77

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I also have an ongoing issue in my upper right quadrant and mid stomach. I have bouts of serious pain, it’s not indigestion, or gas or GERD it’s something different. The pain is about 8/10 and I have a high pain threshold. It’s the third time I’ve had this bout of serious pain in the last 6 months. The first time I had it, it last for 3 days, the pain was there but it was moderate. It was enough for me to report it to my Dr. The second time I had it, the pain was not as bad and lasted about 24 hours. This time, however, the pain was pretty intense, the worst yet, radiating into my back. My abdomen was too tender to touch. I felt like throwing up. The extreme pain lasts about 4 - 5 hours then it lessoned to a 3-4 /10 the next day. My blood sugars went high for several days.
Do you still have your gall bladder?
 
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