Objective To investigate the diagnostic value of endoscopic ultrasound elastography (EUS‑E) in endoscopic ultrasound‑guided fine needle aspiration (EUS‑FNA) for malignant occupying lesions in gastrointestinal adjacent tissue. Methods Clinical data of 54 patients (57 lesions) undergoing EUS‑FNA from January 2020 to April 2021 in the General Hospital of Ningxia Medical University were collected. Thirty patients (31 lesions) who received FNA assisted by EUS‑E from May 2020 to February 2021 were enrolled in the EUS‑E group, and 24 patients (26 lesions) who underwent routine EUS‑FNA without EUS‑E in the non‑EUS‑E group. The diagnostic efficacy of EUS‑FNA was evaluated.The diagnostic efficacy of EUS‑E group and non EUS‑E group was compared. EUS‑E score of EUS‑E group was analyzed. Results The overall sensitivity, specificity, positive predictive value, negative predictive value and accuracy of EUS‑FNA in the diagnosis of malignant occupying lesions in gastrointestinal adjacent tissue were 80.5% (33/41), 100.0% (16/16), 100.0% (33/33), 66.7% (16/24) and 86.0% (49/57), respectively. There were no significant differences in sensitivity [78.6% (22/28) VS 84.6% (11/13), P=0.232] or accuracy [83.8% (31/37) VS 90.0% (18/20), P=0.156] of EUS‑FNA for pancreatic lesions and other lesions (mediastinal and celiac lesions). Postoperative complications occurred in 1 patient (1.85%, 1/54). Also there were no significant differences in sensitivity [84.0% (21/25) VS 81.3% (13/16), P=0.186] or accuracy [87.1% (27/31) VS 88.5% (23/260, P=0.186] of diagnosis of malignant occupying lesions between EUS‑E group and non‑EUS‑E group. In the EUS‑E group, EUS‑E score≥3 was highly consistent with the definite diagnosis (Kappa=0.63). Conclusion EUS‑FNA is a safe and effective cytological and pathological method for diagnosis in gastrointestinal adjacent tissue. EUS‑E score can well predict benign and malignant lesions, but EUS‑FNA assisted by EUS‑E does not show superiority in diagnostic sensitivity or accuracy.