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To improve medical image sharing in applications such as e-learning or remote diagnosis aid, we propose to make the image more usable by watermarking it with a digest of its associated knowledge. The aim of such a knowledge digest (KD) is for it to be used for retrieving similar images with either the same findings or differential diagnoses. It summarizes the symbolic descriptions of the image, the symbolic descriptions of the findings semiology, and the similarity rules that contribute to balancing the importance of previous descriptors when comparing images. Instead of modifying the image file format by adding some extra header information, watermarking is used to embed the KD in the pixel gray-level values of the corresponding images. When shared through open networks, watermarking also helps to convey reliability proofs (integrity and authenticity) of an image and its KD. The interest of these new image functionalities is illustrated in the updating of the distributed users' databases within the framework of an e-learning application demonstrator of endoscopic semiology.