Objective To investigate the value of real-time tissue elastography (RTE) in the differential diagnosis of focal nodular hyperplasia (FNH) and hepatocellular adenoma (HCA). Methods The RTE data of 20 patients with pathologically proven FNH (22 lesions) and 8 patients with HCA (9 lesions) were retrospectively analyzed. The RTE data were evaluated by scores(grades 1-5)and the strain ratios (SR) of the nodules were calculated and compared between the two groups. Results Most FNH lesions had a grade of 3-4(18/22,81.8%)on elastography, while most lesions of HCA had a grade of 1(5/9,55.6%)on elastography, with significant difference found between the two groups (P=0.000 2). The strain ratio of FNH was significantly higher than that of HCA(7.47±4.53 vs 1.64±0.88, P<0.000 1). Conclusion The stiffness of FNH in RTE is notably higher than that of HCA, indicating RTE may be a supplementary to routine ultrasonic examination, which may be helpful for differential diagnosis of FNH and HCA.