Objective To analyze the pancreatic changes in patients with type 2 diabetes mellitus (T2DM) based on ultrasonic elastography, and to analyze their relationship with microvascular lesions. Methods A total of 200 patients with T2DM and 200 healthy controls in the hospital were enrolled as T2DM group and control group between January 2022 and February 2023. The pancreatic size, morphology and internal echo were observed by routine two-dimensional ultrasound. The mean Young"s modulus (Emean) in pancreatic head, body and tail tissues were detected by shear wave elastography. According to the presence or absence of microvascular lesions, patients in T2DM group were divided into lesion group (n=86) and non-lesion group (n=114). The evaluation value of pancreatic changes for microvascular lesions was analyzed by receiver operating characteristic (ROC) curves. Results The proportion of pancreatic hyperecho in T2DM group was higher than that in control group, and diameters of pancreatic head, body and tail were longer than those in control group (P<0.05). Ultrasonic elastography showed that Emean values of pancreatic head, body and tail tissues in T2DM group were greater than those in control group (P<0.05). The difference in pancreatic echo enhancement and diameters of pancreatic head, body and tail between lesion group and non-lesion group was not statistically significant (P>0.05). The difference in Emean values of pancreatic head and tail tissues between lesion group and non-lesion group was not statistically significant (P>0.05). Emean of pancreatic body in lesion group was greater than that in non-lesion group (P<0.05). The area under ROC curve (AUC), sensitivity and specificity of Emean of pancreatic body for evaluating microvascular lesions were 0.758 [95%CI (0.689-0.826)], 74.42% and 71.93%, respectively. Conclusion In T2DM patients, pancreatic echo is enhanced and pancreatic volume is enlarged. Ultrasonic elastography shows that hardness of pancreatic head, body and tail is increased. The hardness of pancreatic body is increased significantly in T2DM patients with microvascular complications.