OBJECTIVE Surgical or endoscopic resection is recommended for the management of gastric high-grade dysplasia (HGD). However, there are no proper guidelines for the management of gastric low-grade dysplasia (LGD). We evaluated clinical parameters, histological results, and endoscopic follow-up to find a management strategy of LGD. METHODS A total of 590 patients with LGD, HGD, functional dyspepsia (FD), and early or advanced gastric cancer (EGC or AGC, respectively) were consecutively enrolled. We examined the association of clinical parameters including low serum pepsinogen (PG) I/II ratio of 3.0 or less with the disease phenotypes. Histological results between initial forceps biopsy and final endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) specimens were compared. Complications and recurrence were evaluated after EMR or ESD. RESULTS The PG I/II ratio in FD was 4.2±1.7 (mean±SD), but was significantly lower in LGD (2.8±1.6, P<0.0001). The PG I/II ratio was not any lower in the HGD, EGC, and AGC groups. In patients with FD having a PG I/II ratio of 3.0 or less, multiple logistic regression analysis showed smoking habits and high salt intake were independent risk factors for gastric dysplasia or gastric cancer. About 11% (n=8/70) of LGD lesions were upgraded to HGD (6/70) or EGC (2/70) after EMR or ESD. Neither serious complications nor recurrence at the primary site after EMR or ESD were found in LGD. CONCLUSION It is proposed that endoscopic resection followed by endoscopic surveillance might be a beneficial strategy for patients with LGD having a PG I/II ratio of 3.0 or less.