Background: HCV is one of the etiologies causing liver fibrosis through direct deposition of extracellular matrix in the liver as a response to wound healing to compensate for the injury Aim of this study: Assessment of liver fibrosis using sonography-based real time elastography (RTE) and FIB 4 score in comparison to liver biopsy for assessment of the stage of liver fibrosis in chronic Egyptian HCV patients. Patients and methods:116 patients with HCV were enrolled in the study from 2014-2015 in the National Hepatology and Tropical Medicine Research Institute Outpatient Clinics, Cairo, Egypt. Results: The mean RTELFI of the studied group was 2.68 ± 0.74. The correlation between different fibrosis stages, FIB-4 and RTELFI showed significant relations between the degree of hepatic fibrosis and FIB-4 with p = 0.001 & RTELFI with p < 0.001. Positive correlation was detected between fibrosis stage, FIB-4 and RTELFI. At a cutoff value of 3.26 for RTELFI, the test had a sensitivity of 72% and a specificity of 90% in detecting advanced fibrosis with AUC = 0.791 (95% confidence interval 0.649-0.933). At a cutoff value of 2.26 for FIB-4 index, the test had a sensitivity of 50% and a specificity of 87% in detecting advanced fibrosis with AUC = 0.797 (95% confidence interval 0.683-0.911). Conclusion: RTE has excellent accuracy for F4 and F ≥ 3 and is superior to FIB-4.