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Evaluating the role of endoscopic ultrasound (EUS) elastography and strain ratio in differentiation between malignant and benign pancreatic lesions.Three hundred twenty-five patients with solid pancreatic lesions were enrolled in this prospective study from 2014 to 2017. EUS real-time elastography scoring and strain ratio were done to all patients and compared to the final diagnosis to assess its sensitivity, specificity, positive and negative predictive values (PPV and NPV) in differentiating malignant from benign lesions.A cut-off value of 4.2 we had sensitivity of 95%, specificity of 63%, PPV of 89%, NPV of 81%, and accuracy of 87%. Another cut-off value of 10.9 showed a sensitivity of 75%, specificity of 88%, PPV of 95%, NPV of 54%, and accuracy of 79%. Adding the elastography to the better cut-off value gave a sensitivity of 97%, specificity of 63%, PPV of 89%, NPV of 88%, and accuracy of 89%.Real-time elastography and strain ration are valuable in differentiating malignant from pancreatic lesions.