Background: Metabolic dysfunction associated steatotic liver disease (MASLD) has emerged as one of the most common liver disorders worldwide and is particularly frequent among patients with Type 2 Diabetes Mellitus (T2DM). In people with diabetes, fatty changes in the liver often develop silently and may progress to fibrosis or advanced liver disease without obvious symptoms. Early identification of liver involvement in this high-risk group is therefore clinically important. Aim: To assess the prevalence and severity of MASLD in patients with T2DM using conventional ultrasonography, with special emphasis on liver fibrosis assessment through Real Time Hepatic Elastography (RTHE), and to compare these findings with biochemical fibrosis scoring. Materials and Methods: This cross-sectional study included 150 patients with T2DM evaluated at a tertiary care hospital over a two-year period. Patients with significant alcohol intake, viral hepatitis, or known hepatotoxic drug exposure were excluded. All participants underwent clinical evaluation, routine laboratory investigations, abdominal ultrasonography to detect fatty liver, calculation of the MASLD fibrosis score, and liver stiffness assessment using RTHE. Fibrosis was graded from F0 to F4 based on Liver Fibrosis Index values. Statistical analysis was performed to determine associations between imaging and fibrosis scoring results. Results: MASLD was identified in 58.7% of patients on conventional ultrasonography. On RTHE, more than half of the patients (53.3%) showed no evidence of fibrosis; however, a significant proportion (36.7%) demonstrated advanced fibrosis (F3–F4), including 26.7% with severe fibrosis. Biochemical fibrosis scoring classified 74% of patients as having definite fibrosis. A significant association was observed between ultrasonographic findings and RTHE grading (p = 0.002), whereas the correlation between RTHE and fibrosis scoring was not statistically significant (p = 0.41). Conclusion: A substantial number of patients with T2DM have underlying MASLD, and many already exhibit advanced fibrosis despite minimal symptoms. Real Time Hepatic Elastography offers valuable non-invasive insight into liver stiffness and may help identify high-risk individuals early. Routine liver assessment in diabetic patients could facilitate timely intervention and potentially reduce long-term hepatic complications.