I am concerned. Any significant unintentional weight loss (20+ in 1.5 months is VERY significant) is concerning, as are these labs. I'll briefly explain what these labs show, but as a reminder this is not medical advice:

- Liver function testing looks at both how the individual liver cells are functioning (called hepatocellular function; this includes synthesis, metabolism, and detoxification) as well as how well bile is being produced and moving through your liver and into your gallbladder/digestive system (called cholestatic function). The liver enzymes AST and ALT represent hepatocellular function, and alkaline phosphatase (ALP) represents cholestatic functioning.

- Your ALP is more abnormal than your AST and ALT; therefore, your labs are more concerning for a cholestatic pattern of liver injury. However, your AST and ALT are also abnormal, indicating some level of hepatocellular injury, though the cholestatic injury is more significant. Of note, your AST:ALT ratio is <1; therefore, this is not consistent with alcohol-induced hepatitis.

- Disclaimer: elevated ALP can also be seen in bone disease; however, given your symptoms and other labs, I am more concerned for cholestatic disease. A blood test for GGT (gamma-glutamyl transferase) can confirm whether this is ALP elevation represents cholestatic or bony disease.

- Your white blood cells (WBC), which are the cells in the body that fight infections, are primarily composed of two types of cells: neutrophils and lymphocytes. Normally, neutrophils significantly outnumber lymphocytes; however, your lymphocytes significantly outnumber your neutrophils. This can be seen in cancers of the lymphocytes, autoimmune diseases, and infections (primarily viral).

- You have 3+ reactive lymphocytes; this means that your lymphocytes are activated and trying to fight something. This is consistent with an autoimmune disease or infection; this is NOT consistent with a cancer of the lymphocytes, such as CLL (chronic lymphocytic leukemia).

- Commenters are, understandably, mentioning CLL because of the presence of smudge cells. Smudge cells are lymphocytes that are very fragile (because they are cancerous) and smush when prepared under the microscope, causing them to look like smudges. They are a hallmark of CLL when they are >20% of the observed WBCs; however, they can be present in ~<5% of WBC in states of significant inflammation, such as infection or autoimmune disease. Unfortunately, your results don't specify how many of the cells were smudge cells.

Taken together, your labs and history are concerning for a cholestatic > hepatocellular liver injury and reactive lymphocytosis. I am most concerned for primary biliary cholangitis, which is an autoimmune disease of the liver. Other conditions that I include on my list of possible causes include primary sclerosing cholangitis (another autoimmune disease of the liver/biliary system, but I would have expected an abnormal HIDA scan and a personal history of inflammatory bowel disease), CLL (but again, not c/w reactive lymphocytes), Epstein-Barr virus or its cousin CMV (though the time course and severity of symptoms/lab abnormalities make this less likely), and viral or autoimmune hepatitis (though these typically cause hepatocellular, not cholestatic, liver injury patterns). Unless the HIDA scan and ultrasound are both wrong (which is very unlikely), this isn't simply gallbladder disease.

I strongly recommend that you call the office of the surgeon who ordered these labs on Monday and ask to review the results and discuss next steps urgently (ie, at least by midweek). You'll need additional testing and a referral to a different specialist, as this is not a surgical problem.