OBJECTIVE: To study the diagnostic value of real-time ultrasound shear wave elastography (US-SWE) in evaluating the histological stages of nonalcoholic fatty liver disease (NAFLD) in a rabbit model. MATERIALS AND METHODS: Twenty-one 8-week-old rabbits were fed a high-fat, high-cholesterol diet (experimental groups), and seven rabbits were fed a standard diet (control group). All rabbits underwent real-time US-SWE at various time points to document the histological stages of NAFLD. We categorized the histological stages as normal, NAFL, borderline nonalcoholic steatohepatitis (NASH), and NASH. We measured the elastic modulus of the liver parenchyma and analyzed the diagnostic efficacy of real-time US-SWE using the area under receiver operating characteristic curve (AUC) for the four histological stages. RESULTS: The mean, minimum, and maximum elastic modulus increase for NAFL, borderline NASH, and NASH. For the mean, minimum, and maximum elastic modulus, AUCs are 0.891 (95% confidence interval [CI]: 0.716–0.977), 0.867 (95% CI: 0.686–0.965), and 0.789(95% CI:0.594–0.919) for differentiating normal liver from liver with NAFLD, respectively; AUCs are 0.846 (95% CI: 0.660–0.954), 0.818 (95% CI: 0.627–0.937), and 0.797(95% CI:0.627–0.913) for differentiating normal liver or liver with NAFL from liver with borderline NASH or NASH, respectively; AUCs are 0.889 (95% CI: 0.713–0.976), 0.787 (95% CI: 0.591–0.918), and 0.895 (95% CI:0.720–0.978) for differentiating liver with NASH from liver with lower severity NAFLD or normal liver, respectively. CONCLUSIONS: Real-time US-SWE is an accurate, noninvasive technique for evaluating the histological stages of NAFLD by measuring liver stiffness. We recommend using the mean elastic modulus to differentiate the histological stages, with the minimum and maximum elastic modulus as valuable complements.