In recent years, endoscopically placed endoprosthesis has become an alternative to traditional operative biliary-digestive bypass in palliative treatment of patients with non-resectable biliary obstruction caused by malignant stricture of the extrahepatic bile duct. In an uncontrolled series the endoscopic approach has been recommended as the treatment of choice.' Alternatively surgery has been recommended primarily because 13% of the survivors needed a later operation for duodenal obstruction.2 The combined intraoperative and postoperative mortality (30 days mortality) after bypass surgery is reported to be 15-30%,2 and the corresponding mortality for the endoscopic approach 10-18%.'3 The procedure related mortality of endoprosthesis insertion was low (0-2%),' and success rates in the application of the stent were high (90%).' Sonnenfeld et al' reported a non-randomised comparison of endoprosthesis versus bypass with 20 patients in each group and found no difference in survival, but the

1) Duodenal polyps are found in 4.6% of patients referred to upper endoscopy and should therefore be looked for. 2) Multiple, small polyps in the duodenal bulb are always benign and need neither biopsy nor treatment (in patients with familial polyposis biopsy is recommended). 3) In the descending duodenum polyps are rare, but a substantial number of them are adenomas. Biopsy is therefore mandatory in this localization.

Immune thrombocytopenia (ITP) is now well-known to reduce patients' health-related quality of life. However, data describing which signs and symptoms patients and physicians perceive as having the greatest impact are limited, as is understanding the full effects of ITP treatments. I-WISh (ITP World Impact Survey) was an exploratory, cross-sectional survey designed to establish the multifaceted impact of ITP, and its treatments, on patients' lives. It focused on perceptions of 1507 patients and 472 physicians from 13 countries regarding diagnostic pathway, frequency and

Cases of de novo immune thrombocytopenia (ITP) - including a fatality - following SARS-CoV-2 vaccination in previously healthy recipients led to studying its impact in pre-existing ITP. In this study, four data sources were analyzed: the Vaccine Adverse Events Reporting System (VAERS) for cases of de novo ITP; a ten-center retrospective study of adults with pre-existing ITP receiving SARS-CoV-2 vaccination; and surveys distributed by the Platelet Disorder Support Association (PDSA, United States) and the United Kingdom (UK) ITP Support Association. Seventy-seven de novo ITP cases were identified in VAERS, presenting with median platelet count of 3 [1-9] x109/L approximately 1-week post-vaccination. Of 28 patients with available data, 26 responded to treatment with corticosteroids and/or intravenous immunoglobulin (IVIG), and/or platelet transfusions. Among 109 patients with pre-existing ITP who received a SARS-CoV-2 vaccine, 19 experienced an ITP exacerbation (any of: ≥50% decline in platelet count, nadir platelet count <30x109/L with >20% decrease from baseline, and/or use of rescue therapy) following the first dose and 14 of 70 after a second dose. Splenectomized persons and those who received 5 or more prior lines of therapy were at highest risk of ITP exacerbation. Fifteen patients received and responded to rescue treatment. In surveys of both 57 PDSA and 43 UK ITP patients, prior splenectomy was associated with worsened thrombocytopenia. ITP may worsen in pre-existing ITP or be identified de novo post-SARS-CoV2-vaccination; both situations responded well to treatment. Proactive monitoring of patients with known ITP, especially those post-splenectomy and with more refractory disease, is indicated.