the accumulation of active metabolites; and an interaction between dihydrocodeine and endogenous opiate-like peptides. Levine3 described an increased narcotic effect of codeine phosphate associated with hypocalcaemia in renal failure; our patient, however, remained normocalcaemic. The convulsions might possibly have been due to toxic dihydrocodeine concentrations,4 but hypertensive encephalopathy was a more likely explanation in the present case. In conclusion we urge caution in prescribing dihydrocodeine in conventional dosage to patients with severely impaired renal function.

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A persistent perineal sinus following proctocolectomy or proctectomy is a not infrequent complication associated with considerable morbidity. Two cases are presented where the perineal sinus was closed using a rectus abdominis flap. This method of closure allows safe, complete excision of the sinus and insertion of a muscle flap which completely fills the defect, enabling complete, primary healing of the perineum.

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